Columbia  ZfiJnibersJftp      V 
in  tfje  Cttp  of  J2eto  gorfe 

College  of  ^fjpsictans  ano  burgeon* 


Reference  Htbrarp 


INTERNAL    MEDICINE 

A  WORK  FOR  THE  PRACTICING  PHYSICIAN 
ON  DIAGNOSIS   AND  TREATMENT 
WITH   A  COMPLETE   DESK   INDEX 

BY 
NATHANIEL  B.  POTTER,  M.D.,  JAMES  C.  WILSON,  M.D. 


IN  THREE  VOLUMES 

ILLUSTRATED  WITH  4S7   TEXT 
ILLUSTRATIONS  AND  14   IN  COLOR 


MEDICAL   DIAGNOSIS 

FIFTH  EDITION  REVISED  AND  ENLARGED  IN  TWO  VOLUMES 

Vol.  I 

MEDICAL  DIAGNOSIS  IN  GENERAL    THE  METHODS  AND  THEIR   IMMEDIATE 
RESULTS;  SYMPTOMS  AND  SIGNS,  TESTS 

BY 

JAMES  C.  WILSON.  A.M.,   M.D. 

Emeritus  Professor  of  the  Practice  of   Medicine  and   Clinical   Medicine  in  the  Jefferson    Medical   (  uUetjc 
and  Physician  to  Its  Hospital  ;    Physician  Emeritus  to  the  Pennsylvania  II..- 
ar.d  Physician-in-ChiVf  to  the  Lankenau  Hospital,  Philadelphia 

ASSISTED   BY 

CREIGHTON   II.  TURNER,  M.D. 


PHILADELPHIA    WD  LONDON 

j.  K.   lippincx)tt  <  omiv 


COPYRIGHT,  igog,  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYRIGHT,  I9IO,  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYRIGHT,  1 91 1,  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYRIGHT,  191 S.  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYRIGHT,  1919.  BY  J.  B.  LIPPINCOTT  COMPANY 
COPYRIGHT,    1920,    BY  J.   B.    LIPPINCOTT  COMPANY 


1xT4-4 


m 


.  .) 


To 

THE     MEMORY    OF    MY 
FATHER 

ELLWOOD  WILSON,  A.M.,  M.D. 


COLLABORATORS 

J.  Leslie  Davis,  M.D. 
Norman  B.  Gwyn,  M.D. 
Frederick  J.  Kalteyer,  M.D. 
James  Hendrie  Lloyd,  M.D. 
Willis  F.  Manges,  M.D. 
William  Pickett,  M.D. 
Martin  E.  Rehfuss,  M.D. 
G.  Canby  Robinson,  M.D. 
William  M.  Sweet,  M.D. 
Corson  White,  M.D. 
William  Reynolds  Wilson,  M.D. 


PREFACE  TO  THE  FIFTH  EDITION 


Four  years  have  elapsed  since  the  last  edition  of  this  work  was  issued. 
To  present  recent  advances  in  diagnostic  methods  and  their  practical  appli- 
cation, several  sections  have  been  rearranged  and  much  new  matter  added. 

The  general  considerations  which  determined  the  original  form  of  the 
work  and  the  arrangement  of  its  topics  and  which  account  in  large  measure 
for  its  prompt  and  wide  acceptance  alike  among  practitioners  and  students 
have  not  been  modified.  But  careful  revision  has  called  for  important 
changes.  Professor  Robinson  has  contributed  a  new  section  on  Graphic 
Methods  in  the  Study  of  Diseases  of  the  Heart;  Professor  Sweet  has  care- 
fully revised  and  enlarged  his  section  on  Diseases  of  the  Eye;  Doctor 
Lloyd  has  brought  the  section  on  Diseases  of  the  Nervous  System  fully  up 
to  date  ;  Doctor  Rehfuss  has  written  one  upon  the  newer  Gastroenterological 
methods  with  especial  reference  to  the  Fractional  Study  of  the  Contents 
of  the  Stomach  and  Duodenum,  and  Doctor  Corson  White,  a  very  practical 
section  on  Serology. 

Focal  Infection,  Vital  Function  Testing  Methods  and  their  Significance, 
Acidosis,  Dehydration  and  Allergy,  Anaphylaxis  and  Sernni  Sickness  have 
been  included  among  the  added  subjects,  together  with  many  important 
minor  matters  incorporated  in  the  text.  Nosological  rearrangements  con- 
cerning  Diseases  of  the  Heart,  Diseases  due  to  Vitamins.  Disorders  of  .Metab- 
olism and  those  arising  in  consequence  of  Deranged  Functions  of  the 
Endocrine  Glands  have  been  made  in  response  to  the  requirements  of  presenl 
views.     Many  new  illustrations  have  been  inserted. 

The  division  of  the  work  into  two  separate  volumes  made  oecessary 
by  the  foregoing  changes  and  its  publication  in  connection  with  Ortner's 
Treatment  of  Internal  Diseases  as  edited  by  Professor  Potter  greatly  in- 
crease its  value  alike  to  the  practitioner  and  the  student  ;  while  the  separate 
general  index  is  a  practical  aid  to  the  use  of  the  three  volumes. 

My  thanks  are  due  to  Dr.  Creighton  II.  Turner  for  efficienl  assistance 
in  seeing  the  work  through  the  press  and  to  Messrs.  -I.  B.  Lippincotl  Com- 
pany for  untiring  and  generous  cooperation. 

J.  c.  Wilson. 

Philadelphia,  April.  P>19. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/internalmedicine01wils 


PREFACE   TO   THE   FIRST   EDITION 


This  volume  has  been  written  partly  in  response  to  the  wishes  of  some 
of  my  professional  colleagues,  partly  to  meet  the  urgent  demands  of  many 
successive  classes  of  pupils,  but  chiefly  in  the  hope  that  at  this  time  a  con- 
venient and  practical  presentation  of  the  subject  of  Medical  Diagnosis  will 
prove  useful  to  the  profession  at  large. 

The  treatment  of  the  subject-matter  under  four  main  headings  has 
been  adopted  with  the  view  of  simplifying  the  arrangement  of  the  topics 
in  a  department  of  medicine  which  has  attained  large  scope  and  insistent 
importance.  It  is  the  confident  expectation  of  the  author  that  this  plan 
will  fulfil  the  twofold  requirement,  that,  within  the  compass  of  a  single 
book,  clinical  phenomena,  on  the  one  hand,  and,  on  the  other,  those  com- 
plexes of  clinical  phenomena  which  constitute  diseases,  are  brought  into 
correlation  in  such  a  manner  that  the  practitioner  who  seeks  information 
upon  an  obscure  case  may  at  once  turn  to  the  discussion  of  the  methods 
available  to  clear  it  up,  and  the  student  may  find  the  definite  clinical  appli- 
cations of  the  same  methods  and  their   results  in  descriptive  medicine. 

Practical  rather  than  theoretical  considerations  have  been  held  con- 
stantly in  view  alike  in  the  treatment  of  the  clinical  and  the  laboratory 
subjects.  To  attain  this  end  a  degree  of  positiveness  of  assertion  not 
warranted  under  other  circumstances  and  the  avoidance  of  the  discussion 
of  moot  and  unsettled  questions  have  seemed  proper. 

The  Medical  Diagnosis  of  J.  M.  Da  Costa  was  published  in  1864.  That 
brilliant  contribution  to  the  literature  marked  an  epoch  in  the  progress 
of  internal  medicine.  From  the  time  of  its  appearance  the  traditional 
conception  of  diagnosis  by  intuition — a  gift  of  the  favored  few — ceased  to 
occupy  the  thoughts  of  medical  men,  and  the  subject  ranged  itself  among 
the  arts  based  upon  scientific  facts.  It  maintained  in  successive  editions 
during  the  life  of  its  distinguished  author  its  position  in  the  forefront  of 
the  progress  of  applied  medicine  during  a  period  of  extraordinary  advance- 
ment in  the  collateral  sciences  upon  which  the  practice  of  medicine  rests. 
The  continuing  rapid  development  of  knowledge  relating  to  the  facts  oi 


viii  PREFACE. 

medicine  in  the  last  decade  has  rendered  necessary  fresh  presentations  of 
the  subject,  and  from  time  to  time  excellent  works  have  appeared.  These 
differ  greatly  among  themselves,  according  to  the  views  of  their  several 
authors,  in  method  and  detail.  To  add  to  this  honorable  list  demands  the 
justification  of  something  different  in  method,  new  arrangement  of  detail,  and 
the  presentation  of  the  whole  subject  in  accordance  with  the  requirements 
of  contemporary  medicine.  It  is  hoped  that  in  the  present  volume  these 
demands  are  fulfilled.  It  is  the  outcome  of  many  years  devoted  to  work 
in  the  wards,  with  the  controlling  side-lights  upon  bedside  diagnosis  afforded 
by  the  clinical  laboratory,  revelations  at  the  hands  of  surgical  colleagues 
in  the  operating  theatre  and  confreres  in  pathology  in  the  post-mortem 
room,  the  frequent  opportunity  of  seeing  unusual  and  grave  cases  in  con- 
sultation, and  long  experience  as  a  teacher.  Such  a  career  arouses  enthu- 
siasm but  begets  caution.  It  does  not  encourage  in  any  way  the  belief 
that  diagnosis  in  medicine  is  an  easy  matter,  Dut  forces  the  conclusion  that 
it  is  often  difficult  and  in  rare  instances  impossible.  For  this  reason  and 
because  we  are  alwa}'s  eager  to  extend  the  boundaries  of  our  knowledge, 
this  art  is  as  absorbing  as  it  is  useful. 

In  the  making  of  a  handbook  of  this  kind  it  is  necessary  to  draw  at 
every  step  upon  the  great  fund  of  acquired  information  which  has  become 
the  common  property  of  the  profession.  To  those  whose  contributions 
have  formed  that  fund  and  to  those  who  are  daily  adding  to  it  I  tender 
grateful  acknowledgment  for  its  use.  I  have  mentioned  by  name  those 
to  whose  work  I  have  especially  referred,  but,  as  a  general  rule,  it  has  been 
impracticable  for  want  of  space  to  append  systematic  references  to  the 
literature. 

The  illustrations  are  in  large  part  drawn  from  personal  observations. 
They  have  been  selected  solely  with  the  view  to  elucidate  the  subject  in 
hand.  Diagrams  have  been  employed  when  this  method  of  presentation 
has  appeared  desirable,  and  the  free  use  of  clinical  charts  constitutes  an 
important  feature  of  the  work. 

To  the  friends  and  fellow-workers  who  have  rendered — some  small, 
some  larger,  but  all  generous  and  willing — assistance,  I  desire  to  express 
my  thanks.  The  list  includes  many  colleagues  in  the  hospitals  with  which 
I  am  connected,  some  who  were  and  others  who  still  are  resident  physi- 
cians.    It  includes  also  Mr.  Wilbert  and  Drs.  Bachmann,  Manges,  Rosen- 


PREFACE.  ix 

berger,  Rowntree,  Royer,  White,  W.  R.  Wilson,  and  J.  Leslie  Davis.  To 
Drs.  de  Schweinitz,  Welch  and  Schamberg,  T.  M.  Rotch,  Packard,  Piersol, 
Young,  Emerson,  Dudley  Fulton,  and  many  others,  together  with  their 
publishers,  I  am  indebted  for  permission  to  use  illustrations.  The 
pages  on  the  diagnosis  of  diseases  of  the  eye  were  written  by  Dr. 
Sweet;  those  on  the  stomach  and  intestines  mainly  by  Dr.  Gwyn; 
those  on  the  nervous  system  by  Drs.  James  Hendrie  Lloyd  and  the  late 
William  Pickett;  those  on  X-ray  diagnosis  by  Dr.  Moore,  and  those  on 
the  examination  of  the  blood,  urine,  sputum,  and  other  fluids  by  Dr.  F.  J. 
Kalteyer.  The  excellent  drawings,  plates,  and  other  illustrations  made 
by  Messrs.  Schmidt  and  Faber  add  much  to  the  usefulness  of  the  book. 
I  am  under  special  and  lasting  obligation  to  Dr.  Kalteyer  for  his  most 
able  and  untiring  aid  while  the  work  was  in  press,  and  to  the  publishers  for 
their  generous  cooperation  at  every  stage  in  its  making. 

J.  C.  Wilson. 

Philadelphia,  September,  1909. 


CONTENTS. 

PART  I. 

OF  MEDICAL  DIAGNOSIS  IN  GENERAL. 

I.  General  Considerations 1 

II.  Medical  Topography 8 

III.  The  Examination  of  the  Patient,  and  Case-taking 39 

PART    II. 
OF  THE  METHODS  AND  THEIR  IMMEDIATE  RESULTS. 

I.  Medical  Thermometry 53 

II.  Physical  Diagnosis.    General  Considerations;    Inspection;    Palpation; 

Mensuration;   Percussion;  Auscultation 61 

III.  The  Examination  of  the  Stomach  and  Intestines 201 

IV.  The  Examination  of  the  Upper  Air-passages  and  the  Ear.    Rhinoscopy; 

Laryngoscopy;  Otoscopy 233 

V.  The  Examination  of  the  Blood 241 

VI.  The  Examination  of  the  Urine 276 

VII    The  Examination  of  the  Sputum 310 

VIII.  The  Examination  of  Transudates,  Exudates,  and  the  Contents  of  Cysts  314 
IX.  The  Examination  of  the  Nervous  System.  Preliminary  Considerations; 
Motor  Symptoms;  Sensory  Symptoms;  Regional  Diagnosis  of  Cere- 
bral Disease;  Aphasia  and  Other  Defects  of  Speech;  Spinal  Local- 
ization; Combined  Degenerations;  the  Reflexes;  Electrodiagnosis; 
Trophic  Disturbances;  Pain  and  Temperature;  the  Muscular  Sense; 

the  Stigmata  of  Degeneration 320 

X.  The  Examination  of  the  Eye 365 

XL  Examination  by  Means  of  Rontgen  Rays 393 

PART  III. 

OF  SYMPTOMS  AND  SIGNS. 

I.  General  Considerations 4  )o 

II.  Appearance;   Temperament  and  Diathesis;   Facieb;    Weight,   Form  and 

Nutrition "^ 

III.  Bones;   Joints;    Musculature;    Posture.   Attitude   and   Gait;    Posture 

and  Movements  OP  Infants *10 

IV.  Temperature;    Heat  Mechanism;    Fever;    Hypothermia;    Significance 

of  Abnormal  Temperatures  5 

V.  Respiration;     Modified    Respiratory    Movements:     Cough    and    Allied 
Phenomena;  Significance  of  Cough  in  Diagnosis;    Expei  [oration  ob 

Sputum 452 

VI.  Circulation;  Pulsation;  Radial  IVi.sk;  Anomalii  3  01  mi    Pulse;  Venous 

Pulse;    Pulsation  of  the  Liver;    Centripetal  Venous  Pulsi      ...    .     */6 

VII.  The  Digestive  System.     The  Mouth;    Lips;    Tilth;    Gums;    TONGUE 

VIII.  The  Digestive  System,  continued.    The  Palate;  Tonsils;   Pharynx  ^06 

xi 


xii  CONTENTS. 

IX.  The  Digestive  System,  continued.    The  (Esophagus 511 

X.  The  Digestive  System,  continued.  General  Symptoms.  Appetite; 
Thirst;  Eructations;  Regurgitation;  Nausea;  Vomiting;  The  Vom- 
itus;  Defecation;  Constipation;  Diarrhcea;  Tenesmus;  Painful 
Defecation;  Fecal  Incontinence;  Character  of  the  Discharges.  .  516 
XL  The  Skin.  Physiological  and  Pathological  Changes  and  Their  Sig- 
nificance; (Edema;  Dropsy;  Superficial  Vascular  Changes;  Skin; 

Nails;  Hair 540 

XII.  Genito-urinary  System.     Micturition;  Urinary  Changes;  the  Repro- 
ductive Organs 564 

XIII.  General  Symptomatic  Disorders  of  the  Nervous  System.    Pain;  Ten- 

derness; Paresthesia 574 

XIV.  General  Symptomatic  Disorders  of  the  Nervous  System,  continued. 

Vertigo;  Convulsions;  Tremor;  Fibrillary  Twitchings 602 

XV.  Psychical    Conditions;    Emotional    States;    Derangements    of    Con- 
sciousness; Insomnia  and  Other  Disorders  of  Sleep 609 

Focal  Infection 621 

Schick's  Test 624 

Acidosis 625 

Dehydration 627 

Functional  Tests 628 

Serology 640 

Allergy;  Anaphylaxis;  Serum  Sickness 652 


LIST   OF   PLATES 


PLATE 

I,     General   Anatomical    Outlines   and   Relations   of  the  Thoracic  and 

Abdominal  Organs 12 

II.     General  Anatomical    Outlines   and    Relations  of    the  Thoracic  and 

Abdominal  Organs 14 

III.  Positions  of  the  Vocal  Cords 238 

IV.  Blood  Corpuscles 270 

V.     1.  Neutrophile      Leukocytosis.       2.  Eosinophilia.       3.  Lymphocytosis. 

4.  Myel.emia 274 

VI.     Tubercle  Bacilli  in  Sputum  .  . . 312 

VII..     Connection     between     Sympathetic    Nerves    Supplying    Viscera    and 

Spinal  Nerves  Supplying  Huscles  of  Abdominal  Walls 344 

VIII.    Varieties  in  the  Normal  Fundus 366 

IX.     Changes  in  Arteriosclerosis .    . .  392 

X.     Changes  in  Retinal  Vessels 392 

XI.     Inflammation  ix  the  Retina 392 


A   HANDBOOK 
of 

MEDICAL  DIAGNOSIS 


VOLUME  I 

DIAGNOSIS  IN  GENERAL;  THE  METHODS-  SYMPTOMS 
AND  SIGNS;  TESTS. 

PART   I. 

OF  MEDICAL  DIAGNOSIS  IN  GENERAL. 


I. 

GENERAL  CONSIDERATIONS. 

Diagnosis  in  medicine  is  the  art  or  process  of  distinguishing  between 
different  diseases.  It  occupies  a  position  related  on  the  one  hand  to  eti- 
ology— that  science  which  has  for  its  object  the  study  of  the  causes  of 
disease — and  on  the  other  to  therapeutics — the  art  of  healing.  To  recog- 
nize a  disease  involves  the  consideration  of  its  causes,  and  if  they  can  be 
corrected  or  removed,  points  the  way  to  a  cure — causa  sublata  tollitur 
effectus.  Even  when  the  causes  are  beyond  our  control  or  the  lesions 
which  they  have  produced  are  permanent,  a  knowledge  of  the  true  nature 
of  the  malady  may  enable  us  to  select  judiciously  the  therapeutic  meas- 
ures by  which  are  brought  about  those  adjustments  which  relieve  suffer- 
ing and  prolong  life.  The  maxim,  "qui  bene  diagnoscit  bene  curat," is  not 
without  truth.  Finally,  a  correct  diagnosis  is  essential  to  a  reasonable 
prognosis,  since  by  this  means  only  can  we  foretell  the  probable  course 
of  a  disease,  whether  it  tends  to  recovery,  to  continuing  disability,  or  to 
death. 

Diagnosis  is  of  fundamental  importance  in  scientific  medicine.  The 
prevention  of  disease  and  the  healing  of  the  sick  constitute  the  goal  of 
medicine,  but  diagnosis  is  the  course  by  which  that  goal  is  to  be  reached. 
Empirical  systems  ignore  alike  the  causal  and  the  pathological  basis  of 
disease  and  content  themselves  with  the  study  and  treatment  of  symptoms, 
and  all  practice  tends  to  degenerate  into  charlatanism  in  proportion  as 
it  allows  itself  to  be  betrayed  into  this  delusion.  Rational  medicine,  on 
the  other  hand,  regards  symptoms  primarily  as  clues  to  a  diagnosis,  only 
secondarily  as  indications  for  treatment;    and  treat  incut  itself  as  efficient 

1 


2  MEDICAL  DIAGNOSIS. 

when  it  is  causal  or  radical,  and  as  a  makeshift  when  it  is  simply  pallia- 
tive or  symptomatic.  When  pain  is  present  we  seek  by  the  methods  of 
diagnosis  to  find  the  cause  of  it  and  to  relieve  it  by  the  removal  of  the 
cause,  and  are  not  content  simply  to  relieve  the  pain  without  regard  to 
the  underlying  condition  which  produced  it. 

The  art  of  diagnosis  is  important  not  only  because  of  its  practical 
utility,  but  also  because  it  deals  with  the  facts  of  nature.  Hypotheses 
and  theories  in  regard  to  disease  come  and  go,  nosological  arrangements 
change  and  shift  like  the  colors  in  the  kaleidoscope,  therapeutic  fashions 
rise  and  fall,  but  the  facts  gained  by  close  and  constant  observation  belong 
to  science  and  are  changeless,  and  these  are  the  facts  with  which  diagnosis 
is  concerned.  It  has  been  said  that  the  whole  art  of  medicine  is  in  obser- 
vation. It  is  certainly  true  that  the  art  of  diagnosis  is  in  observation. 
Errors  occur  far  more  commonly  from  incomplete  observation  than  from 
want  of  knowledge.  A  systematic,  patient,  painstaking  study  of  the  facts 
is  essential  to  success. 

The  requirements  of  this  branch  of  medicine  are  most  varied  and 
exacting.  A  knowledge  of  anatomy,  and  especially  of  visceral  and  regional 
anatomy,  is  essential.  The  variations  in  the  size  and  position  of  the  organs 
within  the  limits  of  health  must  be  known.  The  structure  and  relation 
of  the  parts  entering  into  the  formation  of  the  nervous  system  must  be 
mastered.  The  physiological  functions  of  the  complex  human  organism 
are  to  be  familiar  knowledge.  The  causes  of  disease,  both  those  belonging 
to  the  outside  world  and  those  developed  within  the  body  itself,  and  the 
susceptibilities  which  vary  at  different  periods  of  life  and  under  different 
circumstances,  must  be  thoroughly  understood.  Changes  produced  by 
pathogenic  factors  must  be  clearly  known.  In  truth,  the  facts  of  pathology 
and  semeiology  and  the  natural  history  of  the  diseases  constitute  the 
basis  of  diagnosis. 

Hence,  in  the  arrangement  of  medical  studies,  diagnosis  is  properly 
taken  up  after  the  student  has  made  advanced  progress  in  the  funda- 
mental branches,  and  the  success  of  the  practitioner  in  this  field  of  medicine 
is  dependent  upon  close  habits  of  observation,  accurate  knowledge,  and 
large  experience.  A  judicial  temperament  and  the  ability  to  weigh  evi- 
dence and  assign  due  relative  value  to  the  factors  in  clinical  problems 
are  essential.  Not  less  important  are  patience  and  a  systematic  pro- 
cedure in  all  cases.  Equally  essential  are  correct  habits  of  reasoning, 
since  without  these  a  faulty  conclusion  may  follow  accurately  observed 
facts.  The  diagnostician  in  the  broad  field  of  clinical  medicine  must 
frequently  turn  for  assistance  to  his  professional  colleague,  who  is  familiar 
with  the  facts  of  the  more  restricted  specialties  and  has  mastered  their 
technic,  and  he  is  becoming  with  advancing  knowledge  more  and  more 
dependent  for  accurate  results  upon  instruments  of  precision  and  the 
clinical  laboratory.  Finally,  the  diagnostician  should  not  be  without 
imagination.  Making  use  of  his  knowledge  of  anatomy  and  morbid  anatomy 
he  should  cultivate  the  habit  of  picturing  to  himself  the  changes  in  the 
organs  of  the  body  by  which  clinical  phenomena  are  brought  about,  such 
as  the  consolidated  lung  in  pneumonia,  the  fibrinous  exudate  or  effusion 
in  pleurisy,  the  impacted  gall-stone  in  biliary  fever,  the  thrombus  in  phle- 


GENERAL  CONSIDERATIONS.  3 

bitis,  the  clot  and  its  location  in  cerebral  apoplexy;  and  in  order  that  this 
habit  of  forming  at  the  bedside,  by  a  process  of  projective  imagination, 
mental  pictures  of  structural  conditions  hidden  from  the  eye  may  be 
developed  to  the  greatest  extent,  he  should  avail  himself  of  every  oppor- 
tunity of  witnessing  operations  involving  the  cranium,  thorax,  and  abdo- 
men, and  of  being  present  at  post-mortem  examinations. 

The  object  of  diagnosis  is  not  merely  to  find  a  name  for  a  morbid 
condition  or  symptom-complex.  This  it  does,  it  is  true,  but  in  doing  so 
it  determines  the  condition  of  the  patient  as  an  individual,  the  intensity 
of  the  pathological  process,  the  importance  of  prominent  symptoms,  the 
presence  or  absence  of  complications  or  intercurrent  diseases,  and  in  acute 
maladies  the  ability  of  the  organism  to  withstand  the  attack.  A  correct 
diagnosis  enables  us  to  determine  whether  the  condition  of  the  patient 
is  due  to  causes  still  operative  or  the  result  of  influences  that  have  ceased 
to  act;  whether  or  not  his  malady  is  self-limited,  and,  by  collating  the  facts 
of  any  given  case  with  the  general  knowledge  of  the  profession,  to  form  an 
opinion  as  to  the  probable  duration  of  the  sickness  and  its  ultimate  out- 
come. It  informs  us  whether  the  prominent  symptoms  are  the  direct 
manifestation  of  an  independent  morbid  process,  as  in  gonorrheal  arthritis, 
the  expression  of  a  constitutional  susceptibility,  as  in  rheumatic  fever,  or 
an  acute  outbreak  of  a  persistent  condition,  as  in  podagra.  It  enables  us 
to  recognize  primary  and  secondary  morbid  processes  and  to  distinguish 
between  them,  as  in  appendicitis  and  peritonitis,  and  to  perceive  the  rela- 
tion between  associated  visceral  lesions  due  to  the  same  cause,  or  to  an 
extension  to  the  neighboring  organs,  as  in  the  case  of  left-sided  pleurisy 
with  pericarditis.  It  takes  into  consideration  the  hereditary  tendencies 
of  the  patient,  his  age,  surroundings,  occupation,  mode  of  life  and  habits. 
Diagnosis  is  clearly  the  only  basis  for  rational  therapeutics  and  reasonable 
prognosis.  The  medical  sciences  deal  with  diseases,  the  art  of  diagnosis 
with  individuals.  Disease  is  not  an  entity,  but  the  sum  of  the  phenomena 
of  the  reaction  of  the  organism  to  pathogenic  influences. 

There  are  various  methods  of  diagnosis,  all  of  which  may  be  included 
under  the  two  general  groups  of  direct  and  indirect  diagnosis. 

Direct   Diagnosis. 

A  direct  diagnosis  is  made  when  the  history  of  the  case  and  the  clin- 
ical phenomena  are  sufficient  to  warrant  a  positive  conclusion.  The  his- 
tory of  a  violent  prolonged  chill,  followed  by  high  fever  and  pain  in  the 
chest,  with  cough,  rusty  sputum  containing  pneumococci,  dulness  upon 
percussion  in  the  affected  area,  crepitant  rales,  and  bronchial  breathing, 
justify  a  direct  diagnosis  of  croupous  pneumonia.  The  previous  history 
of  the  attack  is  not  always  necessary,  the  foregoing  associated  symptoms 
and  signs  being  sufficient  for  the  diagnosis  of  pneumonia  even  when  the 
patient  is  delirious  or  too  ill  to  give  an  accounl  of  himself. 

The  direct  method  is  sometimes  described  as  the  semeiological  method. 
The  diagnosis  is  based  upon  the  clinical  phenomena  of  the  disease  and  is 
reached  by  analysis  and  induction.  When  the  data  are  adequate  it  is 
altogether  the  most  scientific  and  satisfactory  method. 


4  MEDICAL  DIAGNOSIS. 

Indirect   Diagnosis. 

The  indirect  method  must  be  employed  when  the  clinical  phenomena  are 
obscure  or  insufficient  for  a  direct  diagnosis.  The  results  are  not  always 
conclusive  and  the  diagnosis  may  remain  for  a  time  one  of  probability. 
This  method  includes  differential  diagnosis  and  diagnosis  by  exclusion. 

The  differential  method  is  based  upon  the  recognition  of  the 
essential  phenomena  by  which  one  disease  may  be  discriminated  from 
others  of  a  group  presenting  similar  manifestations.  A  young  person 
may  present  himself  complaining  of  the  following  symptoms:  Loss  of 
flesh  and  strength,  occasional  irregular  chills,  followed  by  fever  and  sweat- 
ing, shortness  of  breath  upon  exertion,  cough  and  pain  in  the  chest  with 
scanty  expectoration.  Upon  inspection  the  respiratory  movement  of  the 
right  side  is  diminished.  The  right  thorax  is  found  to  be  enlarged  and 
altered  in  contour.  There  is  faint  cyanotic  discoloration  with  cedema  in 
the  infra-axillary  region.  The  heart  is  displaced  to  the  left  and  the  lower 
border  of  the  liver  downward.  Vocal  fremitus  is  enfeebled.  There  is 
marked  dulness  upon  percussion  over  the  lower  part  of  the  chest,  con- 
tinuous with  the  liver  dulness,  while  the  percussion  note  over  the  upper 
portion  has  a  slightly  tympanitic  quality.  Upon  auscultation  the  ves- 
icular murmur  is  faint  and  distant.  Neither  rales  nor  friction  sounds  are 
heard.  The  greater  number  of  these  symptoms  and  physical  signs  may  be 
encountered  in  (a)  abscess  of  the  right  lobe  of  the  liver,  (b)  malignant 
disease  of  the  pleura,  (c)  serofibrinous  pleurisy,  (d)  empyema. 

(a)  Abscess  of  the  right  lobe  of  the  liver  is  comparatively  rare.  There 
is  frequently  a  history  of  dysentery  or  other  disease  of  the  abdominal 
viscera.    The  pus  collection  is  rarely  sufficiently  large  to  displace  the  heart. 

(b)  Malignant  disease  of  the  pleura  is  likewise  a  rare  affection.  It 
usually  develops  insidiously  without  pain.  It  is  not  attended  by  chills 
or  fever  and  does  not  displace  the  heart  or  liver  until  the  growth  has 
attained  unusual  proportions.  It  produces  a  profound  cachexia  and 
usually  involves  rather  than  compresses  the  lung,  so  that  tympany  in  the 
upper  part  of  the  lung  is  absent  and  irregular  patchy  dulness  is  elicited 
over  the  seat  of  the  growth. 

(c)  Serofibrinous  pleurisy  does  not  usually  give  rise  to  fever  or,  even 
when  massive,  to  disturbance  of  the  circulation  of  the  wall  of  the  chest  or 
cedema. 

(d)  The  essential  phenomena  b}r  which,  when  present,  empyema  may 
be  discriminated  from  the  foregoing  affections,  in  addition  to  the  signs  of 
compression  of  the  lung  and  displacement  of  adjacent  organs,  are  chills, 
fever,  sweating,  and  cyanosis  and  oedema  of  the  chest  wall. 

Diagnosis  by  exclusion  differs  from  differential  diagnosis  only  in 
its  scope.  It  seeks  to  establish  the  nature  of  the  disease  by  the  negative 
process  of  showing  what  it  is  not.  The  various  diseases  presenting  similar 
clinical  phenomena  are  compared  in  turn  with  the  case  under  consideration, 
and  one  after  another  excluded,  the  diagnosis  of  that  disease  being  finally 
made  to  which  the  malady  most  closely  conforms.  In  the  above  example 
we  should  first  set  aside  abscess  of  the  liver,  then  malignant  disease  of  the 
pleura,  then  serofibrinous  pleurisy,  and  by  exclusion  arrive  at  the  diagnosis 


GENERAL  CONSIDERATIONS.  5 

of  empyema.  Diagnosis  by  exclusion  is  a  tedious  and  inconvenient  method, 
not,  however,  without  value  in  difficult  and  obscure  cases.  It  may  be 
employed  with  advantage  in  clinical  teaching.    Other  methods  are: 

Causal  or  Etiological  Diagnosis.  —  The  nature  of  an  obscure 
malarial  disease  with  or  without  fever  may  be  determined  by  the  dis- 
covery of  the  aestivo-autumnal  parasite  in  the  blood,  or  the  tuberculous 
basis  of  impaired  health  with  cough  and  obscure  physical  signs  may  be 
revealed  by  an  examination  of  the  sputum.  When  such  a  diagnosis  con- 
cerns germ  diseases  it  is  spoken  of  as  Bacteriological  Diagnosis. 

Hematological  Diagxosis. — This  may  depend  upon  (a)  the  specific 
agglutinating  properties  of  the  serum,  as  in  enteric  fever  or  dysentery;  (b) 
the  morphology,  as  in  pernicious  ansemia  or  leuka?mia;  (c)  the  presence  of 
parasites,  as  in  malaria  or  trypnosomiasis ;  (d)  the  result  of  cultures;  and 
(e)  serodiagnostie  reactions. 

A  provisional  diagnosis  is  that  which  best  accords  with  the  sum  of 
the  probabilities  when  the  data  are  insufficient,  or  pending  a  further  inves- 
tigation of  the  facts.  Such  a  diagnosis  may  serve  as  a  working  hypothesis 
for  therapeutic  purposes  and  the  general  management  of  the  patient. 
It  can  be  revised  or  confirmed. 

A  surgical  diagnosis  is  made  from  the  stand-point  of  the  surgeon, 
and  may  in  proper  cases  be  confirmed  or  set  aside  during  the  life  of  the 
patient  by  an  exploratory  operation. 

Functional  diagnosis  is  the  determination  of  the  degree  of  the 
impairment  of  the  functions  of  organs  caused  by  local  affections  or  the 
extent  of  the  interference  with  physiological  processes  resulting  from 
general  disease,  and  the  bearing  of  such  impairment  or  interference  upon 
the  future  of  the  individual  as  regards  health  and  prolongation  of  life. 
Functional  diagnosis  is  closely  allied  to  prognosis. 

A  therapeutic  diagnosis  is  that  procedure  by  which  in  obscure 
cases  the  nature  of  the  disease  is  determined  by  the  results  of  treatment. 
This  method  is  of  very  limited  application.  A  provisional  diagnosis  of 
malaria  having  been  reached  by  the  process  of  exclusion,  the  patient  may 
be  put  at  rest  and  quinine  administered  in  proper  doses.  Should  the 
symptoms  promptly  disappear,  the  diagnosis  of  malaria  becomes  probable. 
A  similar  diagnosis  of  syphilis  having  been  reached  by  analogous  methods, 
the  subsidence  of  symptoms  upon  the  administration  of  mercurials  or  the 
iodides  may  in  some  cases  confirm  the  diagnosis.  In  almost  all  such  cases 
there  are  other  and  better  methods  of  diagnosis  which  may  l»c  employed 
concurrently  with  the  treatment.  In  grave  or  urgent  cases  it  is.  however, 
better  to  give  the  patient  at  once  the  benefit  of  the  doubt. 

CLINICAL  DIAGNOSIS  is  the  diagnosis  made  at    the  bedside. 

Anatomical  diagnosis  is  the  diagnosis  made  by  the  pathologist  in 
the  post-mortem  room. 

It  is  not    in   all    cases  possible lake   a   positive   diagnosis   at    once. 

Time  may  be  required  for  a  more  thorough  investigation  of  tin-  history  ol 
the  case,  a  closer  si  tidy  of  t  he  pat  ient  's  surroundings,  repeated  observation, 
or  for  the  report  of  examinations  conducted  in  the  clinical  laboratory. 
Information  bearing  upon  the  previous  history  of  the  patient  ><\-  the  be- 
ginning of   his   illness   cannot    always   be  obtained.       lb'   may  be  delirious, 


6  MEDICAL  DIAGNOSIS. 

unconscious,  or  may  have  lost  the  power  of  speech.  The  history  com- 
municated by  his  friends  is  often  uncertain  and  misleading.  Persons  of 
the  lower  classes  are  very  commonly  indifferent  to  symptoms  which  are 
not  painful  or  disabling  and  lack  the  ability  to  describe  their  sensations. 
Many  persons,  on  the  other  hand,  often  intentionally,  sometimes  uncon- 
sciously, make  false  statements  in  regard  to  their  past  life  and  present 
symptoms.  Some  parts  of  the  narrative  are  exaggerated,  others  suppressed. 
Symptoms  may  be  imitated  and  superficial  lesions  artificially  produced. 
Hence  a  group  of  feigned  diseases,  against  which  the  physician  must  be 
upon  his  guard. 

Malingering. — The  term  malingerer  is  used  to  describe  one  who  in- 
tentionally simulates  a  disease.  Malingering  occurs  in  every  grade  of  life 
and  under  various  circumstances.  It  is  to  be  suspected  when  a  simulated 
disease  lacks  essential  symptoms  or  its  picture  is  overdrawn,  and  when 
there  is  lack  of  correspondence  between  the  alleged  symptoms  and  the 
actual  signs  or  the  obvious  general  health;  it  is  to  be  detected  by  close 
study  of  the  case  under  various  conditions,  by  the  use  of  instruments  of 
precision,  and  in  some  cases  by  the  application  of  powerful  faradic  currents 
or  an  examination  under  anaesthesia.  The  over-indulged  child,  to  avoid 
his  lessons  or  escape  punishment,  may  feign  an  illness;  an  older  person, 
to  excite  compassion  or  from  mere  love  of  deception.  It  is  common  among 
beggars,  sailors  and  soldiers,  those  improperly  seeking  pensions,  and  claim- 
ants against  corporations  for  accidental  damages.  The  simulation  of 
disease  is,  however,  not  always  intentional.  Hysterical  and  neurasthenic 
individuals  sometimes  exaggerate  symptoms  or  imitate  the  manifestations 
of  disease  without  purpose  or  intention — the  unconscious  mimicry  of 
disease.  There  are  those,  on  the  other  hand,  who  from  motives  of  delicacy 
or  shame,  or  in  consequence  of  natural  reserve,  or  from  fear  of  having 
their  apprehensions  confirmed,  refuse  to  consult  the  physician,  or  when 
forced  to  do  so  give  a  garbled  and  incomplete  history  of  their  sickness. 
This  may  occur  among  th6se  suffering  from  venereal  diseases  or  chronic 
diseases  popularly  regarded  as  incurable,  as  tuberculosis  and  cancer. 

The  diagnosis  of  an  obscure  case  occasionally  demands  an  investiga- 
tion of  the  surroundings  of  the  patient  at  the  time  of  the  development 
of  the  illness.  Time  may  be  required  to  ascertain  etiological  conditions 
relating  to  his  food,  drink,  occupation,  endemic  influences,  or  exposure  to 
transmissible  diseases  locally  epidemic.  Questions  of  this  kind  frequently 
arise  at  a  period  like  the  present,  when  facilities  for  commercial  intercourse 
are  increasing  and  when  military  operations  and  the  exigencies  of  trade 
have  greatly  extended  travel  to  all  parts  of  the  world. 

Repeated  examinations  may  be  necessary  in  order  to  obtain  accurate 
impressions  when  the  physical  signs  are  obscure  or  ill  defined.  Excessive 
subcutaneous  fat,  local  cedema,  or  general  anasarca  may  interfere  with  the 
physical  exploration;  or  local  tenderness,  intense  pain,  great  restlessness, 
or  an  unwillingness  on  the  part  of  the  patient  to  submit  to  an  examination 
may  give  rise  to  delay.  In  other  cases  the  unusual  character  of  the  symp- 
toms or  an  association  of  clinical  phenomena  not  previously  encountered 
may  render  repeated  examinations  necessary.  During  the  stage  of  invasion 
in  the  acute  febrile  infections  a  positive  diagnosis  is  often  impossible. 


GENERAL  CONSIDERATIONS.  7 

The  advances  of  modern  medicine  have  enormously  increased  our 
knowledge  of  diseases  and  the  precision  of  diagnosis.  In  all  departments 
of  clinical  medicine,  scientific  accuracy  has  taken  the  place  of  probability. 
The  every-day  routine  examinations  of  the  clinical  laboratory  cannot  be 
made  off-hand.  The  more  elaborate  investigations  involved  in  obscure 
cases  demand  technical  skill  and  a  reasonable  time.  The  reports  are 
necessary  to  a  final  diagnosis.  An  immediate  diagnosis  is  not  only  not 
necessary,  it  is  very  often  not  possible.  Haste  involves  the  risk  of  error. 
Conclusions  cannot  be  reached  until  the  premises  are  established.  A 
provisional  diagnosis  may  serve  to  meet  the  immediate  requirements  of 
the  situation.  Treatment  may  be  instituted  in  response  to  urgent  indica- 
tions. When  in  the  period  of  invasion  of  an  acute  illness  there  is  reason  to 
suspect  a  transmissible  disease,  such  as  scarlatina  or  variola,  the  same 
measures  of  prophylaxis  should  be  instituted  pending  the  evolution  of  the 
process  that  would  be  employed  if  the  suspected  disease  were  actually 
present. 

There  are  cases  in  which  diagnosis  in  a  broad  sense  is  impossible. 
A  name  may  be  given  to  some  prominent  symptom  or  group  of  symptoms, 
but  the  essential  pathological  process  may  remain  obscure  until  its  nature 
is  revealed  upon  the  post-mortem  table. 

When  possible  a  positive  diagnosis  should  be  made  at  once;  in  all 
cases  as  soon  as  practicable.  The  student  is,  however,  warned  against 
making  any  but  a  provisional  diagnosis  upon  insufficient  data.  To  ask 
for  delay  is  by  no  means  a  confession  of  ignorance;  on  the  contrary,  it  is 
the  course  dictated  by  knowledge  and  experience.  Intelligent  people, 
who  seek  the  best  professional  advice,  fully  understand  this.  It  is  only 
the  ignorant  who  are  satisfied  with  a  phrase  for  diagnosis,  a  prescription 
dashed  off  at  sight  and  no  directions  whatever,  who  insist  upon  being 
told  what  is  the  matter  at  once. 


II. 

MEDICAL  TOPOGRAPHY. 

Medical  topography  is  that  branch  of  diagnosis  which  has  for  its 
object  the  consideration  of  the  boundaries  and  relations  of  the  external 
parts  and  internal  organs  of  the  body.  Various  points,  lines,  and  regions 
or  areas,  some  artificial,  others  natural,  serve  the  purposes  of  this  method 
of  clinical  investigation. 

THE  HEAD. 

The  head  is  divided  by  anatomists  into  two  parts,  the  cranium  and 
the  face. 

The   Cranium. 

The  skull  encloses  and  protects  the  brain.  It  is  divided  into  regions 
corresponding  with  the  superficial  bones  which  enter  into  the  formation 
of  the  skull, — namely,  occipital,  parietal,  frontal,  and  temporal.  These 
regions  are  separated  by  the  cranial  sutures.  Opposite  the  angles  of  the 
parietal  bones  are  spaces  called  fontanelles, — fons,  a  fountain, — which 
remain  un ossified  after  the  bony  growth  of  the  skull  is  elsewhere  completed. 
Of  these,  two  in  the  median  line,  the  anterior  and  posterior  fontanelles, 
are  important. 

The  regions  of  the  skull  serve  for  the  localization  of  subjective  sensa- 
tions, as  pain  or  headache,  and  superficial  lesions,  as  craniotabes.  nodes, 
nsevi,  injury,  or  suppuration.  The  mastoid  process  of  the  temporal  bone  is 
an  important  landmark,  as  indicating  the  extension  of  middle-ear  disease. 
The  greatest  convexity  in  the  frontal  region  on  either  side  is  known  as  the 
frontal  eminence.  It  is  separated  by  a  slight  depression  below  from  the 
superciliary  ridge,  at  the  level  of  which  in  the  median  line  is  the  nasal 
eminence  or  glabella.  About  the  inner  third  of  the  orbital  arch  is  the 
supra-orbital  notch  or  foramen,  a  point  of  tenderness  in  supra-orbital 
neuralgia. 

Sutures. — Failure  on  the  part  of  the  cranial  bones  to  unite,  with 
persistent  wide  sutures,  may  be  due  to  hydrocephalus,  cretinism,  or  in 
very  rare  instances  to  antenatal  rickets. 

Fontanelles. — Variations  in  Prominence. — Bulging  of  the  fonta- 
nelles is  a  common  symptom  in  infants  and  young  children.  It  is  much 
more  marked  in  the  anterior  fontanelle.  When  persistent  it  indicates 
organic  diseases  of  the  brain,  as  hydrocephalus,  meningitis,  or  intracranial 
hemorrhage,  which  is  in  infants  far  more  commonly  meningeal  than  cere- 
bral. When  transient  it  is  usually  pulsating  and  associated  with  high 
temperature  and  other  symptoms  of  an  acute  febrile  infection. 

Retraction  of  the  fontanelles  occurs  in  chronic  wasting  diseases,  as 
tuberculosis,  infantile  atrophy  or  marasmus,  and  colitis,  and  in  acute 
diarrhceal  affections,  as  enterocolitis  and  cholera  infantum. 


MEDICAL  TOPOGRAPHY.  9 

Variations  in  Size. — The  posterior  fontanelle  is  normally  obliterated 
about  the  sixth  week.  The  anterior  remains  patulous  as  at  birth  or  even 
slightly  increases  in  size  up  to  about  the  ninth  month,  and  closes  before 
the  end  of  the  second  year.  Delay  in  closing  beyond  this  period  is  com- 
monly associated  with  wide  and  ununited  sutures  and  occurs  in  rickets 
and  hydrocephalus.  The  diameter  of  the  anterior  fontanelle  at  the  end 
of  the  first  year  is  normally  about  2.5  centimetres.  A  greater  width  occurs 
in  rickets  and  some  cases  of  congenital  syphilis.  A  very  wide  fontanelle 
is  characteristic  of  hydrocephalus. 

The   Face. 

The  regions  of  the  face  are  the  orbital,  nasal,  buccal,  and  oral.  They 
contain  the  muscles  of  expression  and  are  of  great  importance  in  the  diag- 
nosis of  local  and  constitutional  disease,  as  well  as  in  the  recognition  of 
mental  and  emotional  conditions.  The  facies  in  various  conditions  will 
be  described  in  a  later  chapter.  Changes  caused  by  nervous  and  ocular 
disorders  will  be  considered  under  their  appropriate  headings. 

DEFORMITIES  OF  THE   HEAD   IN   THE   NEWBORN. 

Caput  5uccedaneum. — A  swelling  of  the  scalp  caused  by  pressure 
during  parturition.  The  lesion  consists  of  passive  congestion  with  extrav- 
asation of  blood  and  cedema  of  the  tissues  of  the  scalp  at  the  area  of 
absence  of  pressure,  namely,  the  part  of  pres- 
entation. The  tumor  is  irregularly  circum- 
scribed and  does  not  fluctuate/  It  disappears 
without  treatment  in  the  course  of  a  few  days. 
This  condition  is  to  be  distinguished  from — 

Cephalhematoma.  —  A  tumor  formed 
during  labor  by  hemorrhage  into  the  space 
between  (a)  the  occipitofrontalis  aponeu- 
rosis and  the  periosteum,  or  between  the 
periosteum  and  the  skull  —  external  cephal- 
hematoma—  or  (b),  between  the  skull  and 
the  dura  mater  —  internal  cephalhematoma. 

z    \     t-i  /.  mi  Fig.  1.— Caput  siirroclMiiPinn.     Male,  2 

(a)  EXTBBNAL  (  EPHALHiEMATOMA.— The  hours  old.— Rotoh. 

most    common    variety   is   subperiosteal.     It 

occurs  in  the  form  of  an  irregular,  circular,  flat  tumor  over  one  or.  in 
rare  instances,  both  parietal  bones.  There  is  distinct  fluctuation,  but  the 
overlying  skin  is  not  discolored.  Slight  elevation  of  the  bone  at  the 
border  of  the  swelling  may  be  fell  in  a  few  days,  with  obscure  crepitus. 
The  condition  is  to  be  distinguished  from  caput  succedaneuni  by  its 
location,  fluctuation  upon  palpation,  and  the  examination  of  fluid  with- 
drawn by  aspiration.  The  bony  rim  is  diagnostic  at  a  later  period.  I' 
is  not  to  be  confounded  with  a  depressed  fracture,  which  is  irregular  in 
outline  and  lacks  the  distinct  tumor  formation  with  fluctuation  and  the 
rim-like  bony  circumference  characteristic  of  hematoma. 

(b)  Internal  Cephalhematoma. — A  very  rare  condition  which  enda 
in  the  death  of  the  child.  There  are  pressure  symptoms.  It  is  sometimes 
associated  with  the  external  form.    It  has  occurred  in  breech  presentations. 


«* 


10 


MEDICAL  DIAGNOSIS. 


Fluctuating  tumors  arising  from  the  course  of  the  cranial  sutures  are 
usually  situated  in  the  occipital  region  or  at  the  glabella.  Three  varieties 
are  described. 

Meningocele. — This  term  is  used  to  designate  a  hernial  protrusion  of 
the  meninges  through  an  opening  in  the  bony  cranium  resulting  from 
defective  ossification  or  failure  in  suture  formation.     It  may  result  from 

intra-uterine  hydrocephalus.  The  tu- 
mors usually  contain  cerebrospinal  fluid, 
and  are  translucent,  with  large  veins 
upon  the  surface.  In  some  instances 
an  impulse  may  be  felt  upon  crying 
and  the  tumor  can  be  reduced  by  gentle 
pressure. 

Encephalocele. — This  form  of  cere- 
bral hernia  is  more  common.  The 
tumor  contains  brain  substance  in  addi- 
tion to  the  membranes. 

Hydro=encephalocele.  —  The  her- 
nial contents  consist  of  the  membranes, 
brain  tissue  surrounding  one  of  the  ventricles,  and  a  portion  of  the 
ventricle  itself  distended  with  cerebrospinal  fluid.  These  tumors  vary 
in  size  from  a  walnut  to  a  large  orange  and  tend  to  increase  in  size. 
They  are  usually  pedunculated.  The  prognosis  is  unfavorable,  though 
remarkable  recoveries  have  occurred  after  operation. 

Anencephalia. — This  developmental  defect  is  rarely  complete.  Par- 
tial anencephalia  is  the  usual  form.  In  accordance  with  a  recognized 
pathological  law,  the  deficiency  of  contents  causes  microcephalic  deformity 
of  the  skull. 

Hydrocephalus. — Congenital  internal  hydrocephalus  is  a  common 
cause  of  deformity  of  the  skull  in  the  newborn.  The  head  is  markedly 
enlarged;    the  cranial  bonefe  are    thinned    and    displaced  outwards;    the 


Fig.   2.—  Hydro-encephalocele. — Rotch. 


Fig.  3.— Congenital  internal  hydrocephalus.     Male.  7  months  old. — Rotch. 

sutures  widely  separated  and  the  fontanelles  prominent  and  fluctuating. 
In  marked  cases  the  temporal  and  parietal  bones  flare  outward  so  that  the 
cranium  is  more  or  less  pear-shaped,  the  greatest  diameter  being  in  the 
upper  part.  The  face  is  usually  normal  in  size  but  it  looks  abnormally 
small,  being  dwarfed  by  the  great  size  of  the  head. 


MEDICAL  TOPOGRAPHY.  11 

THE  NECK. 
Length   and   Thickness. 

In  early  infancy  the  neck  appears  short  on  account  of  the  large  size 
of  the  head  and  its  tendency  to  fall  forward,  and  the  relatively  high  posi- 
tion of  the  sternum  and  clavicles.  The  neck  appears  to  be  broad  in  com- 
parison with  its  length  also  by  reason  of  the  large  amount  of  sub- 
cutaneous fat.  In  fact  at  all  periods  of  life  the  thick  neck  of  obese  persons 
appears  short,  an  appearance  heightened  by  the  accumulation  of  fat 
known  as  the  double  chin. 

A  short  thick  neck  and  stout  plethoric  body  constitute  the  chief 
structural  factors  in  the  so-called  habitus  apoplecticus.  On  the  other 
hand,  a  long  slender  neck  with  a  prominent  larynx,  and  narrow  flat  chest 
with  projecting  scapulae,  are  characteristic  of  the  habitus  phthisicus.  But 
both  these  designations  are  misleading,  since  apoplexy  is  dependent  upon 
a  condition  of  the  arteries  and  frequently  occurs  in  spare  persons  with 
long  thin  necks,  and  pulmonary  tuberculosis  is  the  result  of  infection  and 
not  rarely  selects  its  victims  among  those  who  have  well-formed  chests 
and  necks,  and  occasionally  among  those  who  are  stout,  with  short  thick 
necks. 

Contour. 

Larynx. — In  lean  persons  the  larynx  is  prominent  and  forms  the 
projection  anteriorly  in  the  median  line  known  as  the  Adam's  apple.  In 
fat  persons  this  organ  is  much  less  noticeable.  Descent  of  the  larynx  upon 
inspiration  occurs  in  all  forms  of  severe  dyspnoea,  and  especially  in  the 
spasmodic  respiration  which  often  precedes  death  in  respiratory  diseases 
attended  with  stenosis  of  the  larynx  or  oedema,  collapse  or  extensive  con- 
solidation of  the  lungs.  Pressure  displacements  of  the  larynx  and  trachea 
sometimes  result  from  the  presence  of  aneurismal  or  other  tumors  of  the 
neck.  They  are  usually  lateral.  Some  degree  of  lateral  displacement  may 
also  result  from  pleural  adhesions  and  the  traction  of  a  contracting  lung 
in  neglected  pleurisy  or  fibroid  phthisis.  Moderate  bilateral  prominence 
and  enlargement  of  the  neck  without  spastic  contraction  occur  in  the 
habitual  dyspnoea  of  severe  chronic  bronchitis,  emphysema,  bronchial 
asthma,  cardiac  disease  and  certain  cases  of  chronic  uraemia-  so-called 
renal  asthma.  Rigidity  of  the  neck  is  sometimes  due  to  myalgia  of  the 
cervical  muscles,  spondylitis  deformans  involving  the  cervical  vertebrae, 
or  caries.  It  may  be  caused  by  painful  inflammatory  processes,  as  acute 
adenitis,  parotid  bubo,  mumps,  boils,  or  carbuncles. 

Thyroid  Body. — This  gland  is  situated  in  the  Lower  part  of  the  neck 
and  embraces  the  trachea  in  its  upper  part,  reaching  up  to  the  larynx  on 
each  side.  It  consists  of  two  lateral  Lobes  united  by  an  isthmus.  The  right 
lobe  is  usually  slightly  longer  and  wider  than  the  left.  Both  the  larynx 
and  the  thyroid  body  which  is  in  relation  with  it  rise  with  the  act  of  swallow- 
ing. Enlargement  of  the  thyroid  body  usually  affects  the  isthmus  and 
both  lobes,  but  one — very  often  the  right — to  a  greater  extent  than  the 
other.      The    enlargement    may    be    vascular,    parenchymatous,    fibroid, 


12 


MEDICAL  DIAGNOSIS. 


cystic,  or  clue  to  adenoma,  carcinoma,  tuberculosis,  or  gumma.  Vascular 
enlargement  of  the  thyroid  body  may  be  physiological,  occurring  during 
menstruation  or  pregnancy  and  subsiding  at  the  termination  of  these 
events,  or  pathological,  as  in  exophthalmic  goitre,  when  it  is  often  variable 
in  size  and  attended  with  marked  pulsation,  thrill,  and  murmur.  Venous 
hyperemia  may  be  due  to  the  pressure  of  an  aneurism  or  mediastinal 
tumor.    Parenchymatous  enlargement  or  simple  goitre  may  be  of  moderate 

size,  but  in  some  instances  attains 
enormous  dimensions,  protruding 
beyond  the  chin  and  hanging  over 
the  sternum.  Cystic  goitre  when 
multiple  may  be  recognized  by  the 
smooth,  hemispherical,  close  set, 
elastic  nodules  upon  the  surface; 
when  single  and  larger,  by  fluctua- 
tion. Thyroid  abscess  is  rare  and 
usually  accompanied  by  local  inflam- 
matory oedema  and  grave  constitu- 
tional symptoms.  ,  Cancer,  tubercu- 
losis, and  gumma  rarely  involve  the 
thyroid  and  may  be  recognized 
by  their  local  characters  and  the 
associated  constitutional  phenomena. 
An  underlying  aneurism  or  medias- 
tinal growth  may  displace  the  thy- 
roid upwards  and  forwards  or  to 
either  side.  In  aneurism  of  the 
innominate,  the  displacement  is  to- 
wards the  left.  An  aneurism  some- 
times imparts  its  movements  to  the 
overlying  thyroid.  Atrophy  of  the 
thyroid  may  give  rise  to  flattening  of  the  surface.  More  commonly  it  can 
be"  recognized  only  upon  palpation.  It  is  usually  accompanied  by  the 
symptoms  of  cretinism  or  myxoedema. 

Muscles. — One  or  both  sternomastoid  muscles  may  be  hypertrophied 
and  prominent.  In  torticollis  or  wry-neck  the  contraction  is  usually 
unilateral,  and  the  neck  is  rotated  so  that  the  mastoid  is  drawn  towards 
the  inner  end  of  the  clavicle,  the  chin  raised  and  the  face  turned  towards 
the  unaffected  side.  In  rare  cases  wry-neck  is  bilateral, — retrocollic  spasm, 
— the  head  retracted  and  the  face  turned  upward.  The  spasm  in  both 
forms  of  torticollis  may  be  tonic  or  clonic.  The  disease  is  sometimes 
congenital. 

The  Clavicles. — The  position  of  these  bones  has  much  to  do  with  the 
appearance  of  the  neck  as  regards  length.  They  are  high  in  deep-chested 
persons  with  large  lungs  and  in  emphysema;  low  in  flat-chested  indi- 
viduals with  small  lungs  and  in  phthisis  and  pulmonary  fibrosis  from  any 
cause.  These  bones  are  deformed  after  fracture  and  sometimes  present 
nodes  and  irregularities  of  the  surface  caused  by  syphilitic  periostitis. 
Prominence  in  the  retroclavicular  space  sometimes  occurs  in  emphysema 


PLATE  I. 


<  teneral  anatomical  outlines  and  relations  of  the  thoracic  and  abdominal  organs. 


MEDICAL  TOPOGRAPHY.  13 

of  high  grade,  but  as  a  rule  the  clavicles  in  this  condition  are  prominent 
and  both  the  retro-  and  infraclavicular  spaces  are  retracted.  The  sub- 
cutaneous fat  pads  of  myxcedema  are  frequently  seen  above  the  clavicles 
and  sometimes  at  the  root  of  the  neck  posteriorly.  The  neck  is  occasionally 
the  seat  of  extensive  inflammatory  oedema  with  violaceous  discoloration — 
collar  of  brawn — especially  in  scarlet  fever,  erysipelas,  and  infected  wounds, 
and  sometimes  much  distorted  by  subcutaneous  emphysema,  such  as 
follows  rupture  of  the  pleura  or  wounds  or  operations  involving  the  upper 
air-passages. 

THE  THORAX. 

The  thorax  is  of  conical  shape  with  convex  walls.  Its  truncated  upper 
end  is  narrow  and  bounded  by  the  first  dorsal  vertebra,  the  first  pair  of 
ribs,  and  the  manubrium  of  the  sternum.  Its  expanded  base  is  filled  in 
by  the  vault  of  the  diaphragm.  The  anterior  border  of  the  base  curves 
downwards  and  backwards  on  each  side  from  the  xyphoid  cartilage  to  the 
twelfth  rib.  Its  transverse  diameter  greatly  exceeds  its  anteroposterior 
diameter,  which  is  further  shortened  in  the  middle  line  by  the  projection 
of  the  spinal  vertebra?  forwards  into  the  cavity  of  the  thorax.  This  space 
contains  the  heart  and  great  vessels  together  with  the  pericardium,  the 
lungs  and  pleurae,  the  trachea,  the  greater  part  of  the  oesophagus,  and  the 
thymus  gland  or  its  remnant. 

Anatomical  Landmarks  of  the  Thorax. 

ANTERIOR   SURFACE. 

The  Chest. — The  clavicles,  sternum,  ribs,  and  interspaces  constitute 
natural  surface  conformations  to  which,  for  purposes  of  study  and  de- 
scription, clinical  phenomena  may  be  referred. 

The  Clavicles.  —  The  part  immediately  above  these  bones  on  either 
side  is  known  as  the  supra-  or  retroclavicular  space;  that  immediately 
below  them  as  the  infraclavicular  space.  Into  the  supraclavicular  spaces 
the  apex  of  the  lung  enters  to  a  slight  extent,  usually  a  little  further  on  the 
right  than  on  the  left  side.  In  well-developed  lungs  these  spaces  are  not 
retracted,  but  in  ill-developed  lungs  and  in  pathological  states  character- 
ized by  contraction  of  lung  tissue  the}-  arc  more  or  less  strongly  depressed. 

The  Sternum. — The  upper  border  of  this  bone  is  marked  by  a  large 
incurvation  known  as  the  episternal  notch,  which  limits  the  root  of  the 
neck  anteriorly  and  in  which  can  be  felt  at  times  the  pulsating  aorta  - 
dilatation,  dynamic  pulsation,  aneurism  of  the  transverse  arch.  At  the 
line  of  juncture  of  the  manubrium  and  gladiolus  or  body  is  a  more  or  less 
prominent  transverse  line  or  prominence,  better  developed  in  the  male — 
the  angle  of  Ludovicus.  At  the  lower  end  is  the  xyphoid  or  ensiform 
appendix,  variable  in  size  and  shape  and  sometimes  having  its  tip  everted 
in  such  a  manner  as  to  form  an  infrasternal  depression  or  fossa. 

The  Ribs  and  Intercostal  Spaces. — THE  RlBS. —  In  spare  persons  the 
ribs  may  be  counted  with  ease.  When,  however,  then-  is  much  subcu- 
taneous fat,  the  recognition  of  any  particular  rib  is  sometimes  difficult. 
The  first  rib  may  be  known  by  the  articulation  of  its  cartilage  with  the 


14  MEDICAL  DIAGNOSIS. 

sternum  at  a  point  immediately  below  the  articulation  of  the  clavicle. 
The  articulation  of  the  second  costal  cartilage  is  directly  opposite  the 
junction  of  the  first  and  second  pieces  of  the  sternum — angulus  Ludovici. 
The  ribs  slope  downwards  from  their  spinal  articulations  in  such  a  manner 
that  their  chondrosternal  articulations  lie  at  a  much  lower  level,  the  artic- 
ulation of  the  first  rib  anteriorly  being  in  quiet  breathing  on  the  horizontal 
plane  of  the  fourth  rib  at  the  back  and  so  on  to  the  seventh  rib.  In  the 
expiratory  type  of  chest  this  oblique  position  of  the  ribs  is  somewhat 
increased;  in  the  inspiratory  type  it  is  much. diminished. 

The  Intercostal  Spaces. — These  spaces  correspond  to  the  ribs  and 
cartilages  immediately  above  them — that  is,  the  first  space  lies  immediately 
below  the  first  rib.  They  are  wider  in  front  than  behind.  In  expiration 
the  upper  spaces  are  increased  in  width  and  the  lower  narrowed,  while  in 
inspiration  these  conditions  are  relatively  reversed.  It  is  in  accordance 
with  this  fact  that  the  upper  spaces  are  wider  and  the  lower  narrower  in 
the  expiratory,  while  the  upper  are  narrower  and  the  lower  wider  in  the 
inspiratory  form  of  chest.  In  fat  persons  the  intercostal  spaces  cannot 
be  made  out,  but  in  those  who  are  lean  they  appear  as  shallow,  parallel, 
oblique  furrows  symmetrically  arranged  upon  each  side  of  the  chest. 
They  are  deeper  upon  inspiration  than  on  expiration  or  quiet  breathing, 
and  conspicuously  so  in  obstructive  dyspnoea.  These  furrows  are  oblit- 
erated in  massive  pneumonia  and  in  pleural  effusions  and  the  spaces  may 
actually  bulge  in  old  cases  of  large  empyema.  Local  protrusion  of  the 
chest  wall  such  as  occurs  in  large  hypertrophy  of  the  heart  in  early  life 
causes  widening  of  the  overlying  intercostal  spaces.  The  unilateral  flatten- 
ing of  the  chest  which  accompanies  fibroid  phthisis  or  follows  a  neglected 
pleural  effusion,  crowds  the  ribs  together,  even  in  some  instances  to  over- 
lapping, and  in  this  manner  obliterates  the  spaces  in  whole  or  in  part. 

Normal  Cardiac  Pulsation. — The  apex  beat  is  seen  in  the  fifth  inter- 
costal space  to  the  left  of  the  parasternal  line,  while  undulatory  pulsation  in 
several  spaces  occurs  in  dilatation  of  the  heart,  and  heaving  pulsation  over 
a  large  area  in  marked  hypertrophy  of  that  organ.  In  rare  instances  inter- 
costal pulsation  is  due  to  a  neglected  empyema.  The  pulsation  is  almost 
always  in  the  anterolateral  aspect  of  the  chest  upon  the  left  side.  In  mitral 
and  aortic  stenosis,  aortic  insufficiency,  cases  of  congenital  malformation 
of  the  heart,  and  aneurism  of  the  aorta,  thrills  may  be  felt  upon  palpation. 

The  Nipple. — This  organ  is  not  without  value  as  a  topographical 
landmark  in  children  and  spare  males,  but  in  women  and  obese  persons  of 
both  sexes  its  position  is  extremely  variable.  When  there  is  little  fat  and 
the  mammas  are  undeveloped  the  nipple  is  situated  about  the  fourth  inter- 
costal space,  sometimes  over  the  fourth,  sometimes  over  the  fifth  rib,  and 
in  a  vertical  line  intersecting  the  middle  of  the  clavicle — the  mammillary 
line.  It  is  obvious  that  the  nipple  —  mammilla  —  is  not  a  satisfactory 
anatomical  landmark.     The  midclavicular  line  is  much  more  useful. 

POSTERIOR  SURFACE.— THE    BACK. 
The  Spine. — In  children  and  lean  persons  the  spinous  processes  are 
prominent.     In  muscular  adults  and  fat  people  they  are  situated  in  the 
middle  of  a  shallow  longitudinal  groove  formed  by  the  prominence  of  the 


PLATE  II. 


General  anatomical  outlines  and  relations  of  the  thoracic  and  abdominal  <>rCans. 


MEDICAL  TOPOGRAPHY. 


15 


erector  spinse  muscles  on  either  side.  They  become  more  prominent 
when  the  patient  bends  strongly  forward.  Owing  to  the  denseness  of 
the  overlying  musculotendinous  tissues,  the  spines  of  the  upper  five 
cervical  vertebrae  cannot  as  a  rule  be  recognized  upon  palpation.  The 
sixth  may  be  felt  and  seen  in  many  persons,  and  the  seventh — vertebra 
prominens  —  is  usually  con- 
spicuous and  forms  a  point 
of  departure  from  which  the 
thoracic  and  lumbar  spines 
may  be  counted.  The  eighth 
and  ninth  thoracic  spines 
are  normally  somewhat  more 
prominent  than  the  others. 
Marked  prominence  of  one  or 
more  vertebral  spines,  with 
tenderness  upon  pressure  and 
pain  upon  rotary  movements 
of  the  spine  or  jarring,  is  sig- 
nificant of  spinal  caries,  usu- 
ally tuberculous,  rarely  syph- 
ilitic. There  is  frequently 
angular  curvature. 

Kyphosis. — The  curvature 
is  in  the  sagittal  plane  with 
the  concavity  anterior.  It 
is  chiefly  thoracic,  sometimes 
cervicothoracic,  and  may  con- 
stitute nothing  more  than  one 
of  the  skeletal  changes  clue  to 
old  age.  It  occurs  also  in 
those    who    habitually    carry 

heavy  burdens  on  the  head  and  shoulders,  in  emphysema,  rickets,  osteitis 
deformans,  and  acromegaly.  This  rounded  curvature'  is  to  be  distinguished 
from  the  sharper,  often  angular  curvature  of  vertebral  caries  or  mollities 
ossium. 

Scoliosis.  —  A  rotary-lateral  curvature  usually  involving  the  upper 
thoracic  spine  with  compensating  curvature  in  the  lower  thoracic  and 
lumbar  regions.  Less  commonly  it  affects  the  cervical  or  lumbar  regions. 
Scoliosis  is  very  common  in  school-girls  in  consequence  of  poor  muscular 
development  and  faulty  desk  attitudes.  It  may  result  from  the  habitual 
carrying  of  heavy  weights  on  the  same  arm,  inequality  in  the  length  of 
the  legs,  deformity  of  a  foot,  tilting  of  the  pelvis,  old  sciatica,  the  arrested 
growth  of  a  limb  following  infantile  palsy,  hemiplegia,  and  mollities  ossium. 
The  deformity  of  the  chest  following  long-neglected  pleural  effusion  sero- 
fibrinous or  purulent,  includes  dorsal  scoliosis,  t  he  concavity  looking  towards 
the  affected  side. 

Lordosis. — An  exaggeration  of  the  uormal  lumbar  curve  occurs  in  ad- 
vanced pregnancy,  large  abdominal  tumors  and  ascites,  progressive  mus- 
cular atrophy,  and  pseudohypertrophic  muscular  paralysis.     The  attitude 


Fig. 


Spinal  caries.    Lumbal  region. — Younfj 


16 


MEDICAL  DIAGNOSIS. 


in  the  last  condition  is  characteristic.  The  legs  are  separated,  the  head  is 
thrown  back,  the  spine  strongly  curved,  and  the  abdomen  thrust  forward. 
Spina  Bifida. — This  is  a  developmental  fault  consisting  of  failure  on 
the  part  of  the  laminae  of  the  vertebrae  to  unite.  The  usual  site  is  in  the 
lumbar  or  lumbosacral  region.  The  protruding  tumor  is  in  the  middle 
line,  sometimes  covered  with  normal  skin,  sometimes  with  a  thin,  trans- 
lucent membrane.     There  are  two  varieties: 


Fig.  6. — Kyphosis. 


Fig.  7. — Senile  kyphosis. 


Spina  bifida  occulta,  in  which  the  sac  is  walled  off  from  all 
connection  with  the  spinal  canal,   and — 

Spina  bifida  vera,  in  which  the  cyst  is  filled  with  cerebrospinal 
fluid  and  increases  in  size  during  violent  crying,  and  can  be  diminished 
by  gentle  pressure. 

Three  subvarieties  are  recognized: 

Spinal  Meningocele. — The  protruding  membranes  contain  only  cere- 
brospinal fluid. 

Meningomyelocele. — The  sac  contains  not  only  fluid  but  also  sub- 
stance of  the  cord.     This  is  the  most  common  form. 


k 


Fig.  8. — Primary  left  dorsal  scoliosis. — Young. 


K,,,.    id     Spina    bifida    of     umbar    region 
Male,  .'■  y<-ar-  old.— Rotoh. 


I  i  trame  lordosi*  in 
musculai  atrophj       Voung 


MEDICAL  TOPOGRAPHY.  17 

Syringomyelocele. — The  sac  is  formed  of  the  membranes  and  a  pro- 
truding portion  of  the  cord,  the  central  canal  being  dilated  to  form  the 
cavity  of  the  tumor. 

This  group  of  deformities  is  commonly  associated  with  other  develop- 
mental defects.  Exceptionally  spina  bifida  occurs  in  children  otherwise 
healthy  and  well  developed. 

The  Scapulae. — These  flat,  triangular,  trowel-like  bones  are  placed 
symmetrically  upon  the  upper  and  back  part  of  the  thorax  and  extend, 
when  the  arms  hang  by  the  sides  in  the  erect  posture,  from  the  second  to 
the  seventh  ribs.  They  are  attached  to  the  skeleton  by  the  clavicle  and 
the  humerus  and  are  therefore  freely  movable.  When  the  arms  are  folded 
and  the  body  is  bowed  forward,  the  interscapular  space  is  much  increased, 
an  important  fact  in  physical  diagnosis.  The  inner  borders  of  the  scapulae 
project  in  consequence  of  muscular  weakness,  palsy,  and  changes  in  the 
contour  of  the  chest.  Coznbinations  of  these  causative  conditions  may 
occur  in  the  same  case.  Both  inner  borders  project  in  the  alar  or  ptery-, 
goid  chest  and  in  the  progressive  muscular  dystrophies  affecting  the  shoulder 
girdle.  The  abnormal  mobility  of  the  shoulder-blades  arising  from  loss  of 
muscular  tone  permits  the  inner  borders  to  project  like  budding  wings. 
The  inner  border  stands  out  upon  the  affected  side  in  contraction  of  the 
chest  from  pulmonary  fibrosis;  in  associated  serratus  and  trapezius  paraly- 
sis, especially  when  the  arms  are  held  out  in  front  in  the  horizontal  plane; 
in  scoliosis  due  to  various  causes,  and  sometimes  upon  the  left  side  in 
large  aneurism  of  the  descending  portion  of  the  arch  of  the  aorta. 

Immobility  of  the  Spine. — Flexion,  extension,  and  lateral  and  rotary 
movements  may  be  restricted  or  wholly  prevented  by  various  patho- 
logical conditions,  as  (1)  those  giving  rise  to  pain  in  movement,  among 
which  the  more  common  are  traumatism,  myalgia — lumbago — abscess, 
carbuncle,  meningeal  hemorrhage;  (2)  those  involving  spasm,  as  cerebro- 
spinal fever  and  the  spastic  form  of  myalgia;  (3)  those  affecting  the  joints 
and  bones,  most  of  which  terminate  in  ankylosis,  as  traumatic,  gonor- 
rheal, or  tuberculous  disease  and  spondylitis  deformans;  and  (4)  certain 
neuroses,  as  many  of  the  cases  of  so-called  typhoid  spine,  railway  spine, 
hysterical  spine,  irritable  spine,  and  so  on. 

LATERAL   SURFACES. 

The  landmarks  are  the  axilla — armpit — above,  the  anterior  and  poste- 
rior axillary  folds,  the  ribs  and  interspaces  and  the  upper  border  of  hepatic. 
on  the  right,  and  of  splenic  dulness  on  the  left  side,  below.  Enlarged  lymph- 
nodes,  which  frequently  undergo  suppuration  or  may  be  tuberculous,  carci- 
nomatous, leukaemic  or  pseudoleukaemic,  are  common  in  the  axillary  space. 

Artificial    Lines   and   Spaces   of  the  Thorax. 

The  following  conventional  imaginary  lines  and  spaces  serve  a  useful 
purpose  in  the  examination  and  description  of  thoracic  Lesions.  For 
convenience  of  demonstration  the  lines  may  be  marked  upon  the  surface 

with  a  dermatographic  pencil.     The  subject  is  in  the  erect  posture  with 
his  arms  symmetrically  disposed. 


18 


MEDICAL  DIAGNOSIS. 


A.   Vertical   Parallel   Lines.  —  With 
and  last  they  are  double — bilateral. 


the    exception   of   the    first 


(a)  The  mesial  or  midsternal  line. 

(b)  The  line  of  the  sternal  border. 

(c)  The  parasternal  line,  midway  between  the  line  of  the  ster- 

nal border,  and — 

(d)  The  midclavicular  line;  sometimes  spoken  of  as  the  mammil- 

lary  line  because  in  individuals  with  undeveloped  mammae 
it  passes  through  or  near  the  nipple. 


Fig.  11. — Lines  of  reference  :  Anterior. — m,  middle  line; 
8,  s',  right  and  left  lines  of  the  sternal  border;  ps,  ps',  para- 
sternal lines;  c,  c',  midclavicular  or  mammillary  lines. 


Fig.  12. — Lines  of  reference  :  Lat- 
eral.— aa.  anterior  axillary  line;  ma,  mid- 
axillary  line;  pa,  posterior  axillary   line. 


B. 


(e)  The  line  of  the  anterior  axillary  fold. 

(f)  The  midaxillary  line. 

(g)  The  line  of  the  posterior  axillary  fold. 

(h)   The  scapular  line,  passing  vertically  through  the  inferior  angle 
of  the  scapula — a  very  movable  and  uncertain  landmark. 

(i)  The  posterior   mesial  line,   corresponding  to   the  line  of  the 
spinous  processes. 
Horizontal  Parallel  Lines. — These  are  anteriorly: 

(a)  A  line  touching  the  lower  border  of  the  cricoid  cartilage. 

(b)  A  line  passing  through  the  clavicles. 

(c)  A  line  passing  through  the  third  chondrosternal  articulation. 

(d)  A  line  passing  through  the  sixth  chondrosternal  articulation. 


MEDICAL  TOPOGRAPHY.  19 

And  posteriorly: 

(a)  A  line  touching  the  upper  border  of  the  scapulas. 

(b)  A  line  passing  through  the  spines  of  the  scapulas. 

(c)  A  line  passing  through  the  inferior  angles  of  the  scapulae. 

(d)  A  line  touching  the  upper  border  of  the  spine  of  the  twelfth 

dorsal  vertebra. 

Regional   Divisions  of  the    Thorax. 

By  the  intersection  of  certain  of  the  above-described  lines  the  follow- 
ing arbitrary  regions  are  formed: 

(a)  The  Suprasternal  Region. —  This  region  overlies  the  thyroid 
body,  the  trachea,  and  more  deeply  the  oesophagus.  The  transverse  aorta, 
when  dilated,  extends  into  it  and  may  be  felt  pulsating  above  the  level 
of  the  sternal  incisura. 

(b)  The  Upper  Sternal  Region.  —  Beneath  the  breastbone  lie  the 
remnants  of  the  thymus,  the  mesial  borders  of  the  upper  lobes  of  the  lungs, 
and  more  deeply  the  transverse  arch  of  the  aorta. 

(c)  The  Lower  Sternal  Region. — Within  the  limits  of  this  space 
lie  the  mesial  border  of  the  right  lung,  the  termination  of  the  fissure  form- 
ing the  upper  boundary  of  the  middle  lobe,  and  that  part  of  the  right  heart 
which  constitutes  the  area  of  superficial  dulness. 

On  each  side: 

(d)  The  Supraclavicular  Region. — This  space  lies  above  the  upper 
edge  of  the  collar-bone  and  contains  the  apex  of  the  corresponding  lung. 

(e)  The  Clavicular  Region. — A  space  of  no  great  moment  in  diag- 
nosis. It  corresponds  to  the  boundaries  of  the  inner  half  of  the  bone. 
The  clavicle  may  be  used  as  a  pleximeter  in  direct  percussion. 

(f)  The  Infraclavicular  Region. — A  most  important  area  of  the 
chest.  It  is  bordered  above  by  the  line  of  the  clavicles,  internally  by  the 
line  of  the  sternal  border,  externally  by  the  line  of  the  anterior  axillary 
fold  projected  upward  to  the  acromion  process,  and  below  by  the  hori- 
zontal line  passing  through  the  third  chondrostemal  articulation.  It 
contains  on  either  side  that  part  of  the  upper  lobe  <>f  the  lung  in  which 
tuberculous  bronchopneumonia  is  as  a  rule  first  recognizable. 

(g)  The  Mammary  Region. — From  the  lower  border  of  the  preceding 
to  the  line  passing  through  the  sixth  chondrostemal  articulation.  This 
space  contains  on  the  right  side  a  part  of  the  upper  and  middle  lottos  and 
the  fissure  separating  them,  together  with  the  right  auricle  near  the  sternal 
border,  and  more  deeply  in  the  vault  of  the  diaphragm  the  convexity  .if 
the  right  lobe  of  the  liver.  It  overlies  on  the  left  side  the  extrasternal 
area  of  superficial  dulness,  the  apex  of  the  right  and  of  the  left  ventricle, 
and  the  mesial  border  of  the  left  lung  with  the  lingula.  Into  the  mammary 
region  on  each  side  extend  the  interlobar  fissures  of  the  lungs. 

(h)  The  Inframammary  Region. — This  area,  which  extends  from  a 
horizontal  line  through  the  sixth  chondrostemal  articulation  downwards, 
overlies  the  liver  on  the  right  side,  and  upon  the  left  a  portion  of  the  left 
lobe  of  the  liver,  the  fundus  of  the  stomach,  the  transverse  colon,  and  the 
spleen.     On  the  left  is  Traube's  semilunar  space. 


20 


MEDICAL  DIAGNOSIS. 


(i)  The  Axillary  Region. — This  space  is  bounded  by  the  lines  of 
the  axillary  folds  and  the  armpit  above.  It  is  a  diagnostic  territory  of 
some  importance. 

(j)  The  Infra-axillary  Region. — The  upper  boundary  is  the  line 
which  passes  through  the  sixth  chondrosternal  articulation;  its  lower  is 
the  base  of  the  chest.  In  this  region,  upon  the  left,  the  upper  border  of 
splenic  dulness  may  be  demonstrated  upon  percussion.  The  interlobar 
fissure  traverses  the  axillary  and  infra-axillary  spaces. 

(k)  The  Suprascapular  Region. — An  area  of  importance  on  ac- 
count of  the  early  manifestations  of  phthisis. 


fe.V 


Fig.  13. — Regional  divisions  of  the  thorax: 
Anterior. — a,  suprasternal  region;  6,  upper  sternal; 
c,  lower  sternal;  d,d',  right  and  left  supraclavicular; 
e,e',  right  and  left  infraclavicular;  /,/',  mammary; 
g,g',  inframammary. 


Fig.  14. — Regional  divisions  of  the  chest:  Pos» 
terior. — a, a',  supraclavicular  regions;  6,6',  supraspi- 
nous; c,c',  infraspinous;  d,d',  infrascapular;  e.e', 
interscapular  regions. 


(1)  The  Supraspinous  Region. — That  space  lying  between  the  upper 
border  of  the  scapula  and  the  spine  of  the  scapula,  and  occupied  by  the 
thick  supraspinous   muscle. 

(m)  The  Infraspinous  Region.  —  From  the  spine  of  the  scapula 
to  the  level  of  the  inferior  angle.  The  infraspinous  and  infrascapular 
regions  are  traversed  by  the  interlobar  fissures.  This  fact  is  of  importance 
in  the  recognition  of  the  signs  of  the  extension  of  a  tuberculous  infiltra- 
tion to  the  apex  of  the  lower  lobe. 

(n)  The  Infrascapular  Region. — From  the  angle  of  the  scapula, 
namely,  about  the  level  of  the  seventh  rib,  to  the  base  of  the  chest. 

(o)  The  Interscapular  Region.  —  The  space  lying  between  the 
inner  borders  of  the  two  scapulas.  It  extends  across  the  spinal  column 
and  is  much  widened  when  the  arms  are  folded  and  the  body  bent  forward. 


MEDICAL  TOPOGRAPHY.  21 


THE  ABDOMEN. 

The  abdomen  is  the  great  cavity  of  the  body  extending  from  the 
diaphragm  above  to  the  levator  muscles  of  the  anus  below.  It  is  sub- 
divided by  an  oblique  plane  at  the  brim  of  the  pelvis  into  two  portions, 
the  abdomen  proper  and  the  pelvis.  For  the  purpose  of  exact  reference 
to  the  position  and  condition  of  the  organs  contained  in  the  cavity  of 
the  abdomen  in  health  and  disease,  certain  lines,  as  in  the  case  of  the 
thorax,  are  recognized  upon  the  surface.  These  dividing  lines  are  natural, 
and  artificial  or  conventional. 

The  Natural   Lines  of  the  Abdomen. 

(a)  The  linea  alba  in  the  middle  line  from  the  ensiform  cartilage  to 
the  symphysis  pubis. 

(b)  The  line.e  semilunaris,  one  upon  either  side,  passing  from 
the  ninth  costal  cartilage  to  the  pubic  bone  and  following  the  outer  border 
of  the  rectus  abdominis  muscle. 

(c)  The  line.e  transversa,  of  which  there  are  three,  the  upper 
being  at  the  level  of  the  tip  of  the  ensiform  cartilage,  the  middle  at  a 
level  midway  between  the  first  and  the  navel,  and  the  third  at  the  level 
of  the  navel. 

(d)  In  fat  persons  a  deep  transverse  sulcus  or  furrow  crosses  the 
abdomen  a  short  distance  above  the  pubic  arch  and  a  second  similar  but 
less  marked  groove  is  sometimes  seen  about  the  level  of  the  umbilicus. 
These  grooves  vary  in  depth  according  to  the  amount  of  fat  in  the  belly 
wall  and  are  deeper  in  the  erect  than  in  the  recumbent  posture. 

The   Imaginary  or   Conventional   Lines. 

(a)  The  mesial  line,  passing  through  the  tip  of  the  ensiform  car- 
tilage, the  umbilicus,  and  the  symphysis  pubis,  and  corresponding  to  the 
linea  alba. 

(b)  The  prolongation  downward  of  the  midclavicular  line  which 
]>:;^es  through  the  eighth  costal  cartilage  to  the  middle  of  P.oupart's 
ligament    upon   each   side. 

(c)  The  infracostal  line,  passing  around  the  body  in  the  horizon- 
tal plane  of  the  tenth  costal  cartilages. 

(d)  The  bi-iliac  link,  which  corresponds  to  the  plane  of  the  most 
prominent    pari   of  the  iliac  crests. 

These  two  lines  (c)  ami  (d)  divide  the  abdominal  surface  into  three 
zones:  an  upper  or  epigastric,  a  middle  or  umbilical,  and  a  Lower  or  hypo- 
gastric. The  two  vertical  lines  dropped  from  the  middle  of  the  clavicle 
V»  'he  middle  of  Poupart's  ligament  again  divide  each  of  those  zones  into 
three  region-,  as  follows: 

(a)  An  Epigastrk  Region  or  LTppeb  Central  Region. — Tins  over- 
lies ;,  portion  of  the  right  and  left  lobes  of  the  liver  and  a  large  pari  of  the 
anterior  wall  of  the  stomach,  with  the  pylorus,  the  aorta,  the  cceliac  axis. 
the  semilunar  ganglia,  and  at  a  greater  depth  the  pancreas. 


22 


MEDICAL  DIAGNOSIS. 


(b)  A  Right  and  Left  Hypochondriac  Region.— The  right  hypo- 
chondriac region  overlies  the  right  lobe  of  the  liver  and  the  gall-bladder, 
the  duodenum,  the  hepatic  flexure  of  the  colon,  and  the  upper  part  of 
the  right  kidney;  the  left  the  greater  curvature  of  the  stomach,  the  spleen, 
the  tail  of  the  pancreas,  the  splenic  flexure  of  the  colon,  and  the  upper  part 
of  the  left  kidney. 

(c)  An  Umbilical  or  Middle  Central  Region. — In  this  space  lie 
the  greater  curvature  of  the  stomach,  the  mesentery,  the  great  omentum, 
coils  of  the  small  intestine,  and  the  transverse  colon. 


Fig.   15. — Regional  divisions  of  the  abdomen:  Fig.  16. — Quadrants  of  the  abdomen. 

a,  epigastric  or  upper  central  region;  b,b',  right 
and  left  hypochondrium;  c,  umbilical  or  middle 
central  region;  d,d' ,  right  and  left  lumbar  regions; 
e,  hypogastric  or  middle  lower  region. 

(d)  A  Right  and  Left  Lumbar  Region. — The  right  contains  the 
lower  part  of  the  right  kidney,  the  ascending  colon,  and  coils  of  small 
intestine;  the  left  the  lower  part  of  the  left  kidney,  descending  colon, 
and  small  intestine. 

(e)  A  Hypogastric,  Suprapubic,  or  Middle  Lower  Region. — 
This  space  overlies  coils  of  the  small  bowel,  at  its  lower  portion  the  fundus 
of  the  urinary  bladder  when  distended,  and  the  gravid  womb. 

(f)  A  Right  and  Left  Iliac  or  Inguinal  Region.  —  The  right 
contains  the  caecum  and  the  base  of  the  appendix  or  frequently  the  whole 
of  it,  the  ileocecal  valve  and  the  right  ureter;  the  left  the  descending  colon 
and  left  ureter. 


MEDICAL  TOPOGRAPHY.  23 

The  Quadrants  of   the  Abdomen. 

A  simpler  division  of  the  surface  of  the  abdomen  into  regions  may- 
be made  by  a  vertical  and  a  transverse  line  intersecting  at  the  umbilicus. 
The  four  spaces  thus  defined  are  known  respectively  as  the  right  and 

LEFT   UPPER    and    LOWER    QUADRANTS. 

The   Visceral   Regions. 

Certain  important  viscera  give  their  names  to  the  surface  areas  cor- 
responding to  the  situation  in  which  they  are  normally  found.  Thus 
we  speak  of: — 

(a)  The  Precordial  Area;  the  Precordia. — That  part  of  the  chest 
wall  which  overlies  the  heart,  including  the  areas  of  superficial  and  deep 
dulness  and  increasing  in  extent  in  cardiac  dilatation  and  hypertrophy. 

(b)  The  Region  of  the  Apex. — A  more  circumscribed  space  imme- 
diately above  and  around  the  normal  apex  and  shifting  as  the  apex  shifts 
in  enlargement  and  displacement  of  the  heart. 

(c)  The  gastric  area,  which  corresponds  to  the  normal  situation 
of  the  stomach.  The  limits  of  this  region  are  not  strictly  defined,  since  the 
organ  varies  in  size  when  empty  or  distended  with  food  or  gas,  and  has 
some  degree  of  mobility. 

(d)  The  Hepatic  Area. — The  lower  border  of  this  region  is  usually 
sharply  defined  both  in  normal  and  pathological  conditions.  Its  upper 
border  rounds  away  from  the  chest  wall  from  which  the  upper  surface  of 
the  liver  is  separated  by  the  edge  of  the  lung,  and  its  left  border  is  obscured 
by  the  tympany  of  the  stomach  and  colon. 

(e)  The  Region  of  the  Gall-bladder. — The  notch  for  the  gall- 
bladder lies  in  the  under  border  of  the  liver,  slightly  internal  to  the 
ninth  right  costal  cartilage  and  near  the  outer  border  of  the  right 
rectus  muscles.  The  fundus  of  the  organ  when  distended  and  enlarged 
occupies  a  considerable  area  on  both  sides  of  this  point  as  well  as 
below   it. 

(f)  The  Ileocecal  Area. — The  part  of  the  abdominal  surface  lying 
in  the  right  lower  quadrant  of  the  abdomen  and  the  seat  of  the  local 
manifestations  in  appendicitis.  Here  lies  the  spot  of  focal  tenderness 
described  as  McBurney's  point. 

(g)  The  Splenic  Area. — The  region  which  occupies  the  left  hypo- 
chondrium  extending  towards  the  infra-axillary  region.  An  enlarged 
spleen  frequently  transcends  the  normal  borders  of  the  splenic  area, 
and  a  dislocated  spleen  occupies  an  entirely  different  position,  in  such 
a  manner  that  the  normal  dulness  in  the  splenic  area  is  replaced  by 
tympany. 

(h)  The  Sigmoid  Area. — The  left  inguinal  region  and  the  parts 
bordering  upon  it  toward  the  median  lino,  which  arc  so  designated 
because  new  growths  and  other  pathological  conditions  involving  the 
sigmoid  flexure  of  the  colon  give  rise  to  tumors  or  other  clinical  mani- 
festations in  this  portion  of  the  abdomen.  It  corresponds  with  the  left 
lower  quadrant.  « 


24  MEDICAL  DIAGNOSIS. 

(i)  The  Pelvic  Area. — The  designation  sometimes  employed  to  de- 
scribe the  suprapubic  area  because  it  is  the  region  of  the  abdomen  in  which 
enlargements  and  new  growths  of  the  pelvic  viscera  are  frequently  manifest. 

The  extent  of  the  various  regions  of  this  group  is  neither  constant 
nor  well  defined.  Their  borders  are  often  shifting  and  overlapping.  Nev- 
ertheless they  serve  a  useful  purpose  in  the  diagnosis  of  diseases  of  the 
abdominal  organs. 

Large  accumulations  of  fat  in  the  belly  wall  or  within  the  peritoneal 
cavity,  pregnancy,  meteorism,  dropsy  and  ascites,  visceral  displacements 
and  enlargements,  new  growths  and  extra-  and  intraperitoneal  cysts  and 
abscesses  distend  the  abdomen,  modify  its  contour,  and  disarrange,  often 
to  an  extreme  degree,  the  relations  between  the  above-described  areas  and 
the  internal  organs. 

The  foregoing  anatomical  and  conventional  lines  and  areas  enable  us 
definitely  to  fix  the  position  of  clinical  phenomena  for  purposes  of  descrip- 
tion and  record. 

The  signs  or  symptoms  of  a  lesion  may  be  referred  to  a  given  region, 
as  episternal  pulsation,  infraclavicular  dulness,  or  precordial  pain.  More 
exactly  the  location  of  a  given  phenomenon  may  be  indicated  by  the  rib 
or  interspace  in  which  it  is  found  and  the  distance  from  the  midsternal 
line  or  its  relation  to  one  of  the  other  vertical  lines  described,  as,  for  example, 
the  signs  of  a  small  cavity  in  the  second  interspace,  a  measured  distance 
to  the  right — or  left — of  the  median  line;  a  presystolic  thrill  in  the  fifth 
interspace,  to  the  left  of  the  left  parasternal  line;  an  undulatory  impulse 
in  the  fourth,  fifth,  and  sixth  interspaces,  extending  to  a  point  midway 
between  the  left  midclavicular  line  and  the  line  of  the  anterior  axillary  fold. 

A  tumor  or  painful  spot  in  the  abdomen  may  be  located  in  one  of  the 
nine  regions  described  as  the  epigastric,  right  iliac,  hypogastric,  and  so  on, 
or  in  one  of  the  quadrants  of  the  abdomen. 

If  greater  accuracy  is  desired,  the  position  of  a  lesion,  physical  sign, 
or  tender  spot  may  be  stated  to  be  a  measured  distance  to  the  right  or 
left,  as  the  case  may  be,  of  the  middle  line  at  the  level  of  the  umbilicus, 
or  a  measured  distance  above  or  below  the  level  of  the  umbilicus.  Or, 
again,  the  anterior  superior  spine  of  the  ilium  may  be  taken  as  the  point 
of  departure  for  similar  measurements. 

In  the  back  the  spinous  processes  may  be  taken  as  points  of  departure 
for  the  measurements.  Thus  a  lesion  may  be  a  measured  distance  from 
the  middle  line  on  a  level  with  the  eighth  dorsal  spine  or  over  a  numbered 
interspace  or  rib. 

The  unit  of  measurement  may  be  the  centimetre,  or  the  inch,  if  pre- 
ferred, or  the  finger's  breadth  which  equals  about  2  centimetres  or  %  inch, 
or  the  hand's  breadth,  which  varies  from  about  9  to  11  centimetres  or 
3^  to  4^  inches. 

It  is  customary  to  indicate  the  extent  of  a  lesion  or  the  size  of  a  tumor 
by  less  accurate  but  significant  anatomical  measurements;  thus  we  say 
of  a  splenic  tumor  that  it  extends  to  the  crest  of  the  ilium  or  to  the  sym- 
physis pubis  or  beyond  the  median  line,  or  of  a  distended  bladder  or  en- 
larged uterus  that  it  reaches  halfway  from  the  pubis  to  the  umbilicus  or 
to  the  level  of  that  anatomical  landmark.       » 


Fig.  17  — Semidiagrammatic  reconstruction,  showing  relations  of  pleural  sacs  (blue)  ami  lungs  (red    to 

thoracic  wall;    anterior  a.-pect. 


Flo.   18  —Semidiagrammatic  reconstruction,  showing  relations  of  pleural  sacs  (blue)  and  lungs  (red)  t<> 

I  pect. 


MEDICAL  TOPOGRAPHY.  25 

THE  TOPOGRAPHICAL  ANATOMY  OF  THE 
THORACIC  ORGANS. 

The  Thymus  Gland  and  its  Remnants. 

This  temporary  organ  attains  its  maximum  development  about  the 
end  of  the  second  year.  It  then  undergoes  a  gradual  involution  process 
until  it  is  reduced  to  a  mere  vestige.  When  fully  developed  it  appears 
as  a  narrow  elongated  body  lying  in  the  anterior  mediastinal  space  imme- 
diately behind  the  manubrium  sterni  and  extending  into  the  episternal 
region  of  the  neck.  Its  size  varies  according  to  the  degree  of  development. 
At  birth  it  is  about  6  centimetres  in  length,  2.5  centimetres  in  width,  and 
.75  centimetre  in  thickness.  The  thymus  is  occasionally  persistent  and 
may  then  undergo  hypertrophy.  In  this  case  and  when  enlarged  as  the 
result  of  tuberculous,  syphilitic,  or  cancerous  disease,  or  hemorrhagic  or 
purulent  infiltration,  pressure  symptoms,  namely,  paroxysmal  dyspnoea — 
so-called  thymic  asthma — persistent  dyspnoea,  spasm  of  the  glottis,  or 
venous  hyperemia  and  local  cedema  arise. 

The  Trachea  or  Windpipe. 

This  tubular  organ  extends  in  the  median  line  from  the  larynx  to  a 
point  opposite  the  third  dorsal  vertebra,  where  it  is  crossed  in  front  by  the 
arch  of  the  aorta,  and  there  or  immediately  below  this  level  it  bifurcates  into 
the  right  and  left  bronchi.  Its  length  is  variable,  being  in  the  adult  about 
9  to  11  centimetres,  its  width  from  2  to  2.5  centimetres.  It  is  both  wider 
and  longer  in  the  male  than  in  the  female.  The  trachea  is  movable  and 
may  be  displaced  as  well  as  compressed  by  an  aneurism  or  a  new  growth. 
Its  posterior  membranous  part  is  in  relation  with  the  oesophagus  behind, 
and  the  recurrent  laryngeal  nerves  ascend  in  the  groove  between  these 
two  organs.  The  manubrium  sterni  overlies  the  trachea,  which  traverses 
the  posterior  mediastinum. 

The  Primary  Bronchi. 

The  right  and  left  bronchi  arise  at  the  bifurcation  of  the  trachea  and 
diverge  to  the  corresponding  lung  upon  each  side,  which  they  respectively 
enter  at  the  root  to  form  by  successive  subdivisions  the  ramifications  of 
the  bronchial  tree.  The  right  bronchus — the  wider  and  shorter  of  t  he  i  wo  — 
passes  obliquely  downwards  and  outwards  to  the  lung  at  the  level  of  the 
fourth  dorsal  vertebra,  and  behind  the  aorta;  the  left,  smaller  in  diameter 
but  much  greater  in  length,  runs  obliquely  downwards  and  outwards 
below  the  arch  of  the  aorta  to  the  rool  of  the  left  lung,  into  which  it  pa 
at  the  level  of  the  body  of  the  fifth  dorsal  vertebra.  The  length  of  the 
right  bronchus  is  about  2.5,  that  of  the  left  nearly  5  centimetn 

Irregular  stenosis  of   the  trachea  or  a   main   bronchus,   from   an   aneu- 
rismal  or  neoplastic  tumor  or  from  a  tenacious  and  adherent  exudate.  C8 
tracheal  stridor  and  the  accumulation  of  an  abundanl   liquid  exudate,  as 
in  some  forms  of  bronchitis,  and  the  pulmonary  oedema  thai   precedes 
death  gives  rise  to  coarse  tracheal  rales. 


26  MEDICAL  DIAGNOSIS. 

Elasticity  of  the  Tracheobronchial  Structures. — That  these  organs 
have  a  high  degree  of  pliability,  analogous  to  that  of  the  vesicular  structure 
of  the  lung,  is  shown  by  the  manner  in  which  they  accommodate  them- 
selves to  the  displacing  and  distorting  pressure  of  effusions,  aneurism,  and 
new  growths  of  various  kinds  without  great  impairment  of  their  function. 
That  they  possess  equally  remarkable  capacity  of  elongation  and  contrac- 
tion has  been  recently  demonstrated  by  X-ray  examination  and  the 
bronchoscope  of  Chevalier  Jackson. 

The  (Esophagus :    Gullet. 

This  tubular  organ  extends  from  the  pharynx  at  the  lower  border  of 
the  fifth  cervical  vertebra — the  level  of  the  cricoid  cartilage — along  the 
anterior  surface  of  the  borders  of  the  vertebras,  to  pass  through  the  dia- 
phragm about  the  level  of  the  ninth  dorsal  vertebra  and  end  in  the  cardiac 
orifice  of  the  stomach.  Its  length  is  about  23  centimetres.  In  the  thorax 
it  lies  posterior  to  the  lower  part  of  the  trachea,  the  upper  part  of  the  left 
bronchus,  and  the  posterior  surface  of  the  pericardium.  The  oesophagus 
may  be  the  seat  of  simple  or  syphilitic  cicatricial  stricture;  stenosis  from 
cancerous  growth  involving  its  wall  or  pressing  upon  it  from  without  or 
from  the  external  pressure  of  an  aneurism.  Spasmodic  stricture  occurs  in 
neurotic  and  hysterical  persons,  and  the  impaction  of  a  foreign  body,  as  an 
artificial  denture,  a  large  piece  of  meat,  or  a  bone,  may  cause  mechanical 
obstruction,  an  accident  that  occasionally  occurs  among  the  insane.  It  is 
sometimes  the  seat  of  a  diverticulum.  The  oesophagus  is  accessible  to  exam- 
ination by  the  sound,  the  cesophagoscope,  and  X-rays.  The  time  occupied  in 
swallowing  and  the  nature  of  the  accompanying  sounds  may  be  studied  by 
auscultation. 

The  Lungs  and  Pleurae. 

The  lungs  occupy  the  greater  part  of  the  cavity  of  the  chest,  enclosing 
between  their  concave  inner  surfaces  the  heart  and  great  vessels.  Each 
lung  is  attached  to  the  inner  wall  of  the  thorax  in  the  region  of  the  bodies 
of  the  fourth  and  fifth  dorsal  vertebras  by  a  comparatively  small  pedicle 
called  the  root,  and  a  narrow  membranous  fold  continued  downwards 
from  it.  Elsewhere  the  surface  of  the  lung  is  free  and  covered  by  a  serous 
membrane,  the  pleura,  which  is  also  reflected  upon  the  inner  wall  of  the 
chest.  The  root  of  each  lung  is  composed  of  the  respective  main  bronchus 
together  with  large  blood-vessels,  lymphatic  vessels,  chains  of  lymphatic 
glands,  held  together  by  connective  tissue  and  enclosed  in  the  pleura. 

THE  PLEUR/E. 

Each  pleura  is  a  closed  serous  sac,  lining  the  lateral  cavity  of  the 
thorax  to  which  it  belongs,  enclosing  the  lung  and  its  root  and  forming 
by  the  aid  of  its  fellow  of  the  opposite  side  the  mediastinum.  That  part 
of  the  pleura  which  encloses  and  covers  the  lung  and  its  root  is  called 
the  visceral  or  pulmonary  pleura;  that  which  is  reflected  upon  the  ribs 
and  intercostal  spaces,  covers  the  upper  convex  surface  of  the  diaphragm, 
and  passes  to  the  sides  of  the  pericardium,  thus  forming  the  mediastinum, 


Fig.   19. — Semidiagrammatic  reconstruction,  showing  relations  of  right  pleural  sac  (blue)  and  lung  ued 

to  thoracic  wall;  lateral  aspect. 


Fig.  20. — Semidiagrammatic  reconstruction,  showing  relations  <>f  lefl  pleural  sac   blue)  and 

thoracic  wall;  lateral  aspect. 


MEDICAL  TOPOGRAPHY.  27 

is  called  the  parietal  pleura,  or  —  as  to  its  different  parts  —  the  costal, 
diaphragmatic,  and  mediastinal  pleura;  and  these  two  parts — namely, 
the  visceral  and  the  parietal  pleura — are  continuous  with  each  ot'^er  at 
the  root  of  the  lung. 

The  upper  part  of  the  pleura  on  each  side  passes  upward  beyond  the 
clavicle  into  the  neck,  and  contains  the  apex  of  the  lung,  which  reaches 
from  2.5  to  4  centimetres  above  the  margin  of  the  first  rib.  usually  a  little 
higher  upon  one  side  than  upon  the  other,  but  not  constantly  higher  upon 
the  right  side  as  is  often  stated.  Beneath  the  sternum  the  pleural  sacs  of 
the  two  sides  come  nearly  or  quite  into  contact  in  the  upper  part,  but  in 
the  lower  part  the  right  pleura  passes  to  or  even  beyond  the  middle  line 
and  the  left  pleura  recedes  from  it  to  a  variable  distance  beyond  the  sternal 
border.  At  the  base  of  the  chest  the  pleurae  do  not  reach  to  the  attachments 
of  the  diaphragm,  but  they  are  reflected  from  the  inner  wall  of  the  chest  to 
the  rising  vault  of  the  diaphragm  in  such  a  manner  that,  on  quiet  respira- 
tion or  on  full  expiration,  the  parietal  and  visceral  pleurae  are  not  in  apposi- 
tion, but  the  costal  and  diaphragmatic  surfaces  of  the  parietal  pleura  are 
opposed.  The  higher  position  of  the  right  diaphragmatic  vault,  due  to  the 
high  position  of  the  right  lobe  of  the  liver,  renders  the  right  pleura  somewhat 
shorter  than  the  left,  while  the  smaller  portion  of  the  heart  upon  the  right 
side  of  the  median  line  renders  the  right  pleura  somewhat  wider  than  the  left. 

THE   LUNGS. 

Each  lung  is  cone-shaped— with  its  blunt  apex  extending  into  the 
root  of  the  neck,  its  anterior  surface  flattened,  its  lateral  and  posterior 
convex  surfaces  strongly  convex,  and  its  inner  and  inferior  surfaces 
concave.  The  contour  resulting  from  this  conformation  gives  rise  to 
sharp,  well-defined  anterior  margins,  the  horizontal  sections  of  which  are 
acutely  angular,  and  to  a  similar,  sharply  angular,  circumferential  border 
at  the  base,  which  fits  into  the  corresponding  re-entrant  angle  between  the 
thoracic  wall  and  the  diaphragm — a  fact  of  no  little  importance  in  physical 
diagnosis.  rCach  lung  is  divided  by  a  long,  deep  fissure,  beginning  about 
the  level  of  the  spine  of  the  scapula  and  proceeding  obliquely  downward 
and  outward  to  the  sixth  rib  in  the  niidaxillary  line,  into  an  upper  and 
a  lower  lobe.  The  right  lung  is  further  divided  by  a  second,  shorter  fis- 
sure, which  passes  inward  either  straight  or  in  an  upward  or  downward 
direction  through  the  anterior  margin,  thus  forming  a  third  or  middle 
lobe.  Upon  the  inner  anterior  border  of  the  left  lob;>  is  situated  a  deep 
notch  into  which  the  heart,  enveloped  in  its  pericardium,  is  received,  and 
at  the  inferior  part  of  this  border  of  the  lung  is  situated  a  tongue-like 
projection  which  passes  in  front  of  the  apex  of  the  heart — lingula. 

The  lungs  completely  fill  the  chest,  and  the  surfaces  of  the  visceral 
and  parietal  pleura'  are  accurately  in  contact  excepl  along  the  anterior 
and  inferior  margins  of  the  lungs.  In  these  situation-  the  -harp  wedge- 
like  borders  of  the  lung  advance  between  the  reflected  layers  of 
the  parietal  pleura  during  inspiration  ami  recede  during  expiration,  as 
above  stated. 


28  MEDICAL  DIAGNOSIS. 

The  Mediastinum. 

This  space  lies  between  the  layers  of  an  anteroposterior  septum 
formed  by  the  inner  or  mesial  portions  of  the  right  and  left  pleurae  which 
pass  upon  the  surface  of  the  pericardium  from  the  anterior  and  posterior 
walls  of  the  chest  to  the  root  of  the  lung  upon  either  side.  It  is  subdivided 
into  an  anterior,  middle  and  posterior  mediastinum. 

The  anterior  is  narrow  and  of  little  depth,  lying  directly  behind  the 
inner  surface  of  the  sternum.  At  its  upper  part  it  contains  the  atrophied 
thymus.  Behind  the  gladiolus  the  right  and  left  pleurae  are  in  contact, 
and  the  anterior  mediastinum  consists  merely  of  the  connective-tissue 
layer  by  which  they  are  joined.  Lower  down,  while  still  shallow,  it  is 
widened,  by  the  departure  of  the  left  pleura  from  the  midsternal  line,  into 
a  triangular  space  which  lies  between  the  anterior  portion  of  the  right 
ventricle  and  the  wall  of  the  thorax — the  area  of  superficial  cardiac  dulness. 

The  middle  mediastinum  is  the  large  space  between  the  mesial  layers 
of  the  two  pleurae  which  contains  the  pericardium  and  its  contents. 

The  posterior  mediastinum  lies  in  front  of  the  vertebral  bodies  and 
contains  the  trachea,  the  oesophagus,  the  thoracic  duct,  the  descending 
aorta,  the  azygos  vein,  lymphatic  vessels  and  the  pneumogastric  nerves. 

THE  PERICARDIUM. 

This  membranous  sac,  which  occupies  the  middle  mediastinum  and 
contains  the  heart  and  the  roots  of  the  great  blood-vessels,  is  conical 
in  shape,  its  base  resting  upon  the  diaphragm  and  its  apex  extending 
upwards  upon  the  walls  of  the  blood-vessels  as  far  as  their  first  sub- 
divisions. It  consists  of  two  layers,  an  external  fibrous  layer,  which 
is  attached  below  to  the  central  tendon  of  the  diaphragm,  and  above 
to  the  surface  of  the  large  blood-vessels  which  it  embraces,  and  an  inner 
serous  layer,  which  lines  the  fibrous  sac  in  which  the  heart  is  contained  and 
is  reflected  upon  the  surface  of  that  viscus  in  such  a  manner  as  to  form  a 
parietal  and  a  visceral  portion.  The  latter  is  sometimes  described  as  the 
epicardium.  The  fibrous  pericardium  is  furthermore  firmly  attached  to  the 
structures  by  which  it  is  surrounded,  namely,  the  sternum  in  front,  the 
mediastinal  pleurae  laterally,  and  the  trachea,  oesophagus,  and  main  bronchi 
behind. 

The  Heart  and  Great  Vessels. 

THE  HEART. 

This  central  organ  of  the  circulation  is  situated  in  the  cavity  of  the 
thorax  in  the  middle  mediastinum.  It  lies  unattached  within  the  peri- 
cardium except  by  the  great  vessels  which  spring  from  its  cavities  at  the 
base,  and  it  rests  upon  the  convexity  of  the  diaphragm.  Its  base  is  directed 
upward,  backward,  and  toward  the  right,  and  extends  from  the  level  of  the 
fourth  to  that  of  the  eighth  dorsal  vertebra,  while  its  apex  points  down- 
ward, forward,  and  toward  the  left,  coming  into  relation  with  the  chest  wall 
in  the  fifth  intercostal  space  a  little  to  the  left  of  the  parasternal  line.  It 
projects  farther  to  the  left  of  the  median  line  than  to  the  right  in  the 
average  ratio  of  nearly  2  to  1. 


MEDICAL  TOPOGRAPHY. 


29 


Orthodiagraphic  measurements  have  shown  that  the  average  oblique 
diameter  of  the  heart  from  the  true  apex  to  the  angle  at  the  upper  right 
border  of  the  auricle  and  the  great  vessels  is  between  13  and  14  centimetres; 
the  horizontal  distance  from  the  midsternal  line  to  the  most  distant  point 
of  the  border  of  the  heart  on  the  right,  3.5  to  4.5  centimetres;  to  the  most 
distant  point  on  the  left,  7.5  to  8.5  centimetres. 

The  Relation  of  the  Heart  to  the  Anterior  Wall  of  the  Chest. — In 
general  the  normal  heart  in  the  adult  may  be  said  to  extend  from  the  level 
of  the  second  intercostal  space  on  the  right  side  to  the  fifth  interspace  on 
the  left.  Investigations  conducted  to 
ascertain  the  exact  relations  of  the 
viscus  to  the  chest  wall  by  thrusting 
long  needles  through  it  immediately 
after  death,  by  means  of  sections  of 
frozen  bodies,  and  by  the  X-rays  have 
not  yielded  constant  nor  concurrent 
results.  The  discrepancies  are  doubt- 
less due  to  differences  existing  natu- 
rally among  individuals  and  to  variable 
conditions,  in  themselves  equally  in- 
capable of  exact  determination:  for  ex- 
ample, the  position  of  the  diaphragm, 
the  amount  of  residual  air  in  the 
lungs,  the  quantity  of  gas  in  the  stom- 
ach and  intestines,  and  the  volume  of 
blood  in  the  chambers  of  the  heart  at 
the  time  of  examination.  For  clinical 
purposes  it  is  possible  to  be  over- 
exact  in  variable  matters  of  this  kind. 

The  greater  part  of  the  anterior 
surface  of  the  heart  is  not  directly  in 
relation  with  the  inner  chest  wall,  but 
separated  from  it  by  the  wedge-like 
anterior  borders  of  the  lungs.  The 
superior  border  of  the  heart  closely 
corresponds  to  a  transverse  line  drawn 
about  the  level  of  the  upper  edges  of 
the  third  costal  cartilages  and  extending  from  a  point  two  centimetres  from 
the  right  border  of  the  sternum  to  the  third  loft  costochondral  articula- 
tion. This  line  constitutes  the  clinical  base  of  the  heart  and  subdivides 
the  precordia  into  the  cardiac  area  and  the  area  of  the  great  vessels. 

The  inferior  border  is  indicated  by  a  line  drawn  from  a  point  on 
the  upper  border  of  the  sixth  rib,  directly  below  the  outer  limit  of  the 
impulse,  obliquely  upward  and  to  the  right,  across  the  base  of  the  •uni- 
form cartilage,  and  terminating  at  the  middle  of  the  fifth  right  interspace 
near  its  junction   with   the  sternum. 

The  right   border  nearly  coincides  with  a  line  drawn    from   the   point 
at  which  the  superior  border  terminates  on  the  right,  convex  to  the  right, 
to  the  middle  of  the  fifth  interspace  as  above,  namely,  about  2  centime! 
to  the  right  of  the  right  sternal  border. 


FlO.  21.  —  Outline  of  heart  and  tinea  indi- 
cating the  auriouloventrioular  groove  *nd  'lie 
anterior  interventricular  groove. 


30  MEDICAL  DIAGNOSIS. 

The  left  border  is  marked  by  a  line  joining  the  apex  and  the  articula- 
tion of  the  third  left  rib  with  its  cartilage. 

A  line  joining  the  third  left  chondrosternal  articulation  and  the  seventh 
right  chondrosternal  articulation  corresponds  fairly  well  with  the  line  of 
the  auriculoventricular  septum. 

A  line  joining  the  apex  and  the  third  left  costochondral  articulation 
corresponds  closely  with  the  interventricular  septum. 

The  greater  part  of  the  anterior  surface  of  the  heart  is  formed  by  the 
right  ventricle  and  constitutes  a  triangle  included  between  the  above  lines 
and  the  inferior  border  of  the  heart.  The  apex  of  this  triangle  is  occupied 
by  the  conus  arteriosus  and  the  tip  of  the  left  auricular  appendix. 

The  upper  third  of  the  right  auricle  lies  behind  the  sternum,  while 
its  two  lower  thirds  extend  to  the  right  of  the  sternal  edge  and  are  bounded 
by  the  curved  right  border  of  the  heart. 

The  left  auricle  is  deeply  seated  and  is  completely  covered  by  the 
body  of  the  heart  and  the  left  lung. 

The  left  ventricle  is  likewise  deeply  seated  and  wholly  retired  from 
the  surface  of  the  chest  with  the  exception  of  a  narrow  longitudinal  strip 
which  forms  the  left  border  of  the  heart  and  presents  anteriorly,  and  of 
which  the  lower  end  constitutes  the  true  or  anatomical  apex  of  the  heart, 
and  is  separated  from  the  chest-wall  by  the  lingula,  the  clinical  apex  to 
which  the  impulse  is  due  being  the  apex  of  the  right  ventricle. 

That  portion  of  the  anterior  surface  of  the  heart  which,  uncovered 
by  the  borders  of  the  lungs,  comes  into  relation  with  the  wall  of  the  chest, 
constitutes  the  area  of  superficial  cardiac  dulness  and  may  be  more  or  less 
accurately  defined  by  percussion;  that  which  recedes  by  its  rounded  sur- 
faces from  the  chest  wall  and  is  covered  by  a  rapidly  thickening  volume 
of  lung  tissue  is  described  as  forming  the  area  of  deep  cardiac  dulness  and 
cannot  be  defined  with  the  nicety  which  some  assume  by  the  ordinary 
methods  of  physical  diagnosis,  though  the  shadow  of  its  borders  may  be  seen 
expanding  and  contracting  with  the  revolutions  of  the  heart  upon  X-ray 
examination. 

THE  GREAT  VESSELS. 

The  ascending  arm  of  the  arch  of  the  aorta  arises  at  the  base  of  the 
left  ventricle  of  the  heart  behind  the  pulmonary  artery.  Its  course  is  at 
first  upward  and  to  the  right  and  slightly  forward  as  it  passes  behind  the 
sternum.  At  the  level  of  the  second  right  costal  or  aortic  cartilage,  the 
vessel  passes  upward,  backward,  and  to  the  left,  forming  the  transverse  por- 
tion of  the  arch,  then  backward  and  downward  to  form  the  descending  arm 
of  the  arch  which  terminates  in  the  descending  portion  of  the  thoracic  aorta. 

The  pulmonary  artery  passes  a  little  more  than  a  centimetre  beyond 
the  left  border  of  the  sternum  in  a  line  about  the  level  of  the  middle  of 
the  left  third  interspace  upward  to  the  second  costal  cartilage,  behind  which 
it  divides  into  its  right  and  left  main  branches. 

The  descending  vena  cava  extends  from  the  second  interspace  on  the 
right  side  of  the  sternum  to  the  base  of  the  heart,  which  it  enters  at  the 
level  of  the  middle  of  the  third  interspace.  Its  course  is  slightly  curved, 
the  convexity  being  toward  the  right. 


MEDICAL  TOPOGRAPHY. 


31 


These  vessels  are  situated  at  varying  depths  behind  the  manubrium 
sterni  and  in  an  area  extending  beyond  the  right  and  left  sternal  borders. 
This  region  is  sometimes  designated  the  area  of  the  great  vessels. 

The  Relation  of  the  Valves  of  the  Heart  to  One  Another  and  to  the 
Surface  of  the  Chest.— The  lines  of  attachment  of  the  bases  of  the  mitral 
and  tricuspid  valves  correspond  to  the  auriculoventricular  sulcus.  The 
semilunar  cusps  of  the  aortic  and  pulmonary  valve  systems  are  situated 
respectively  at  the  origin  of  each  of  those  vessels  from  the  ventricles. 
The  four  sets  of  valves  lie  in  close  proximity  to  <  no  another  and  to  some 
extent  overlap.  The  pulmo- 
nary is  most  superficial;  the 
mitral  most  deeply  situated: 
the  aortic  centrally  placed  and 
in  parts  of  its  extent  covered 
by  the  pulmonary;  and  the 
tricuspid  lowest  in  position. 

Their  relations  to  the  sur- 
face of  the  chest  are  as  follows: 

The  pulmonary  valve  lies 
horizontally  immediately  to  the 
left  of  the  sternal  border  at 
the  level  of  the  upper  edges  of 
the  third  left  costal  cartilage. 

The  aortic  valve  is  at  a  level 
slightly  lower  than  the  pulmo- 
nary and  situated  behind  the 
sternum  at  the  level  of  the  third 
left  intercostal  space  and  to 
the  left  of  the  median  line. 
It  is  nearly  horizontally  placed. 

The  mitral  valve — left 
auriculoventricular  —  lies  on 
an  oblique  line  from  above 
downward  to  the  right  behind 
the  sternum  extending  from 
the  level  of  the  left  third  inter- 
costal space  to  the  level  of  the  lower  border  of  the  left  fourth  costal  cartilage. 

The  tricuspid  valve — right  auriculoventricular — lies  still  nunc  obliquely 
behind  the  sternum  opposite  the  fourth  intercostal  space  on  a  line  drawn 
through  a  point  in  the  midsternal  line  on  the  level  of  the  third  interspace  to 
the  sixth  chondrosternal  articulation. 

These  four  valve  systems  are  so  close  to  one  another  thai  bhe  Bounds 
produced  by  each  cannot  be  studied  by  auscultation  directly  over  the  sent 
of  the  valve,  but  at  that  point  in  the  precordia  at  which  the  blood  stream 
at  the  moment  directly  affecting  the  particular  valve  mechanism  approaches 
the  surface  of  the  chest  most  closely. 

Puncta  Maxima. — These  areas,  of  which  there  are  four,  corresponding 
to  the  separate  valve  systems,  arc: 

1.  The  pulmonary  area — at  the  inner  end  of  the  second  left  intercostal 
space. 


]  ig.  22. — Position  of  1  k-:i rt  and  valves  in  relation  t" 
anterior  thoracic  wall.  A,  aortic  valve;  1'.  valve  <>f  pul- 
monary  aorta;  T,  tricuspid  valve;  M,  mitral  valve;  and 
puncta  maxima  indicated  by  red  circles. 


32  MEDICAL  DIAGNOSIS. 

2.  The  aortic  area — at  the  second  right  costal  cartilage. 

3.  The  mitral  area — at  and  just  above  the  position  of  the  apex-beat. 

4.  The  tricuspid  area — at  the  right  border  of  the  lower  end  of  the  sternum. 

THE  TOPOGRAPHICAL  ANATOMY  OF  THE 
ABDOMINAL  VISCERA. 
The  Stomach. 

The  stomach  is  that  dilated  portion  of  the.  alimentary  canal  which 
lies  between  the  cardiac  end  of  the  cesophagus  and  the  pyloric  end  of  the 
duodenum.  It  is  irregularly  gourd-shaped,  the  larger  left  end  being  called 
the  fundus  or  splenic  extremity;  the  smaller  right  end  the  pyloric  extremity. 
The  orifice  by  which  the  cesophagus  enters  is  called  the  cardia  or  cardiac 
orifice,  that  passing  to  the  duodenum  the  pylorus.  The  former  is  imme- 
diately below  the  central  part  of  the  diaphragm  and  lies  between  the  greater 
and  lesser  curvatures.  The  latter  lies  lower  down,  more  toward  the  anterior 
abdominal  wall,  and  to  the  right.  The  shorter  inner  curvature  of  the 
gourd  is  known  as  the  lesser,  the  longer  outer  curvature  is  the  greater 
curvature  of  the  stomach.  This  hollow  viscus  lies  chiefly  in  the  epigastric 
and  left  hypochondriac  regions,  the  greater  part  of  its  extent  being,  when 
distended,  in  about  the  proportion  of  1  to  5,  to  the  left  of  the  median  line. 
During  physiological  rest  the  healthy  stomach  contains  only  a  little  mucus 
and  a  small  accumulation  of  air  or  gas  which  occupies  its  fundus,  and 
forms  a  narrow  wrinkled  pouch,  the  long  diameter  of  which  is  oblique  from 
the  cardia  downward  and  to  the  right  and  approaches  much  more  nearly 
to  the  vertical  than  to  the  transverse  axis  of  the  body.  Its  superior  border 
is  fixed  at  the  cardia  at  the  point  at  which  the  cesophagus  pierces  the  dia- 
phragm and  is  attached  to  the  overlying  liver  and  diaphragm  by  the 
gastrohepatic  omentum  and  the  gastrophrenic  ligament.  The  gastrocolic 
omentum  is  attached  to  the  lower,  the  gastrosplenic  omentum  to  the  left 
border.  The  anterior  surface  is  in  relation  with  the  diaphragm  and  under 
surface  of  the  liver  above  and  the  wall  of  the  abdomen  lower  down;  the 
posterior  surface  is  in  relation  with  the  great  vessels  and  pancreas  above 
and  the  transverse  mesocolon  lower  down.  Both  these  surfaces  are  free, 
smooth,  and  invested  with  peritoneum.  When  the  stomach  is  distended, 
it  rotates  upon  its  cardiopyloric  axis  in  such  a  manner  that  the  anterior 
surface  tends  to  look  upward  and  the  posterior  surface  downward.  The 
dimensions  of  the  stomach  vary  according  to  the  degree  of  distention  caused 
by  food,  fluid,  or  gas.  When  moderately  filled,  its  longest  diameter  is  about 
25  centimetres,  its  diameter  between  the  greater  and  lesser  curvature  from 
9.5  to  12  centimetres,  and  the  diameter  between  its  anterior  and  posterior 
walls  about  9  centimetres.  When  much  distended,  a  normal  stomach  may 
reach  to  the  level  of  the  umbilicus. 

The  cardia  is  situated  in  a  direct  line  posterior  to  the  left  seventh 
chondrosternal  articulation  at  a  distance  of  about  10  to  12  centimetres 
from  the  anterior  abdominal  wall.  The  pylorus,  which  has  considerable 
freedom  of  motion,  lies  about  the  level  of  the  tip  of  the  ensiform  cartilage 
and  near  the  outer  border  of  the  right  rectus  muscle.    It  is  in  relation  with 


MEDICAL  TOPOGRAPHY.  33 

the  concave  surface  of  the  liver  and  may  extend  to  the  neck  of  the  gall- 
bladder. When  the  stomach  is  distended  the  pylorus  assumes  a  position 
further  to  the  right  and  lower  in  the  abdomen.  The  fundus  rises  into  the 
vault  of  the  diaphragm  to  the  level  of  the  fifth  interspace  in  the  midaxillary 
line  and  is  higher  than  the  cardia,  just  as  the  lateral  vault  of  the  diaphragm 
is  higher  than  its  central  aponeurosis.  Its  upper  part  lies  behind  the  anterior 
diaphragmatic  border  of  the  left  lung  and  the  tips  of  the  seventh,  eighth, 
and  ninth  left  ribs  and  their  cartilages.  The  convex  curve  of  Traube's 
semilunar  space  in  this  region  corresponds  with  the  curvature  of  the  fundus 
of  the  stomach. 

The  Intestines. 

A.  The  small  intestine  begins  at  the  pylorus  and  terminates  at  the 
ileocecal  valve,  at  which  point  it  joins  the  large  bowel.  It  has  an  average 
length  in  the  adult  of  about  six  metres.  Its  convolutions  occupy  the  middle 
parts  of  the  abdomen  and  are  surrounded  by  the  large  intestine.  They  are 
attached  to  the  back  wall  of  the  abdominal  cavity  by  the  mesentery. 
The  small  intestine  is  divided  into  (1)  an  upper  portion,  or  duodenum, 
about  25  to  30  centimetres  in  length,  into  which  in  its  middle  third  the 
common  bile  duct  and  pancreatic  duct  discharge  their  contents;  (2)  a 
middle  portion,  or  jejunum;  and  (3)  a  lower  portion,  or  ileum.  In  the  last 
are  situated  Peyer's  patches.  The  duodenum  is  the  widest  and  least  mov- 
able of  the  three  portions  of  the  intestines.  The  coils  of  the  jejunum  and 
ileum  are  freely  movable  within  the  abdomen  and  among  themselves  and 
bear  no  constant  relation  to  the  regions  of  the  surface. 

B.  The  large  intestine  extends  from  the  termination  of  the  small 
intestine  at  the  ileocecal  valve  to  the  anus.  Its  average  length  is  between 
1.5  and  2  metres.  Its  diameter  varies  at  different  parts  and  ranges  from 
3.5  to  6  centimetres.  There  is  a  pouch-like  dilatation  of  the  rectum  im- 
mediately above  its  lower  end.    It  is  divided  into  three  parts. 

(1)  The  Caecum  ;  Intestinum  Caecum ;  Caput  Caecum  Coli. — The  shortest 
and  widest  part  of  the  large  intestine.  It  measures  in  length  and  width 
each  about  6  centimetres.  As  a  rule,  there  is  no  mesocsecum,  and  this 
part  of  the  intestine  is  attached  to  the  fascia  covering  the  right  iliacus 
muscle.  The  csecum  is  situated  in  the  right  iliac  fossa  and  is  comparatively 
fixed.  Its  position  determines  that  of  the  ileocecal  valve  which  lies  bel  ween 
6  and  7  centimetres  mesial  to  the  right  anterior  superior  spinous  process. 

(2)  The  appendix  vermiformis  arises  from  the  inner  and  posterior 
aspect  of  the  csecum  near  the  ileocecal  valve.  It  lies  in  the  right  iliac  region 
and  its  base  is  opposite  McBurney's  point.  Its  dimensions  are  extremely 
variable,  its  width  being  that  of  a  large  quill  and  its  Length  from  6.5  to'.)  cen- 
timetres. From  its  comparatively  fixed  base,  the  appendix,  being  free,  may 
extend  in  any  direction.  Asa  rule  it  lies  downward  or  inward.  It  may, 
however,  extend  backward,  in  which  case  the  symptoms  of  appendicitis  may 
suggest  renal  colic;  or  upward,  and,  if  inflamed,  Buggest  gall-bladder  disease. 

(3)  The  Colon. — This  part  of  the  Large  intestine  constitutes  its  great- 
est length.  It  occupies  the  peripheral  parts  of  the  abdominal  cavity,  and, 
owing  to  the  lack  of  a  mesocolon  in  its  ascending  and  a  portion  of  its 
descending  course,  maintains   a   comparatively    fixed    position.      In    some 

3 


34  MEDICAL  DIAGNOSIS. 

instances  there  is  a  short  mesocolon  in  these  portions.  It  is  divided, 
according  to  its  course  and  direction,  into  four  parts,  namely,  an  ascend- 
ing, a  transverse,  a  descending  portion,  and  the  rectum. 

(a)  The  ascending  colon,  commencing  at  the  caecum,  passes  upward 
in  a  vertical  direction  to  the  under  surface  of  the  liver  near  the  gall-bladder, 
where  it  turns  forward  and  sharply  to  the  left,  forming  the  hepatic  flexure. 
It  is  as  a  rule  fixed  in  its  whole  course  and  overlaid  by  some  coils  of  the 
ileum.     It  is  contained  in  the  right  lumbar  and  hypochondriac  regions. 

(b)  The  transverse  colon  passes  across  the  umbilical  region  from  the 
right  to  the  left'  hypochondrium.  It  is  deeply  situated  at  its  right  and  left 
extremities,  but  in  its  intermediate  course  it  bends  forward  and  approaches 
the  anterior  wall  of  the  abdomen — arch  of  the  colon.  It  rises  slightly  at  its 
left  extremity  to  pass  behind  the  costal  margin  in  relation  with  the  fundus 
of  the  stomach  and  turns  abruptly  downward  to  form  the  splenic  flexure. 

(c)  The  descending  colon  is  continuous  with  the  transverse  colon  at 
the  splenic  flexure.  It  descends  nearly  directly  downward  through  the  left 
hypochondrium  and  lumbar  region  to  the  left  iliac  region,  where  it  curves 
inward  and  then  downward  to  form  the  sigmoid  flexure.  The  descending 
colon  is  covered  only  in  front  and  at  its  sides  by  peritoneum,  but  the  sig- 
moid flexure  has  a  distinct  mesocolon  and  is  freely  movable.  The  latter  lies 
well  toward  the  front  of  the  cavity  of  the  abdomen  in  the  left  iliac  region. 

(d)  The  rectum,  notwithstanding  its  name,  is  not  straight  in  man, 
but  curved  from  its  beginning  at  the  brim  of  the  pelvis  in  front  of  the  left 
sacro-iliac  articulation  obliquely  downward  from  left  to  right  to  the  middle 
line  of  the  sacrum,  then  forward  in  the  hollow  of  the  sacrum  to  the  level 
of  the  prostate  in  the  male  or  the  vagina  in  the  female,  where  it  again  turns 
and  proceeds  downward  and  obliquely  backward  to  the  anus.  This  part 
of  the  large  intestine  lies  entirely  within  the  pelvis,  but  is  accessible  to 
examination  by  the  finger,  the  rectal  bougie,  and  the  proctoscope. 

The  Liver. 

The  liver  is  the  largest  gland  in  the  body  and  occupies  a  great  space 
in  the  abdominal  cavity.  It  measures  from  22  to  24  centimetres  in  its 
transverse,  about  15  centimetres  in  its  maximum  anteroposterior,  and 
14  to  16  centimetres  in  its  maximum  vertical  diameter.  It  is  bulky  and 
rounded  in  its  right  extremity;  narrow  and  wedge-shaped  toward  the  left; 
convex  and  smooth  upon  its  upper  surface;  concave,  uneven,  traversed 
by  various  fissures,  and  showing  the  gall-bladder  and  extrahepatic  bile  pas- 
sages upon  its  lower  surface.  The  rounded,  thick  posterior  part  is  the  most 
fixed;  the  thin,  sharp  anterior  margin  the  most  movable  part  of  the  organ. 

The  liver  occupies  the  right  hypochondriac  and  extends  across  the 
epigastrium  into  the  left  hypochondriac  region.  It  is  closely  adapted  to 
the  vault  of  the  diaphragm  and  is  in  relation  with  the  anterior  wall  of  the 
abdomen  on  the  right  side  as  far  down  as  the  margin  of  the  ribs.  The  right 
lobe  reaches  higher  than  the  left — a  fact  in  accord  with  the  shorter  vertical 
diameter  of  the  right  thorax  as  compared  with  the  left.  At  its  highest 
point  the  convex  upper  surface  of  the  right  lobe  of  the  liver  corresponds? 
to   the   fourth  intercostal   space   in   the   midclavicular    line.      The    upper 


MEDICAL  TOPOGRAPHY 


35 


boundary  gradually  declines  to  the  base  of  the  ensiform  cartilage  in  the 
direction  toward  the  left  and  continues  on  the  right  and  to  the  back  almost 
upon  the  same  level,  crossing  the  midaxillary  line  at  the  level  of  the  seventh 
intercostal  space  and  the  line  of  the  angle  of  the  scapula  about  the  level  of 
the  ninth  rib.  Owing  to  the  dome-like  shape  of  the  upper  surface  of  the 
right  lobe  of  the  liver  and  the  concavity  of  the  base  of  the  lung  into  which 
it  is  adapted,  the  diaphragm  being  interposed,  there  is  a  considerable 
difference  in  the  level  of  the  actual  upper  border  of  the  organ  and  that  of 
the  portion  which  lies  in  contact  with  the  wall  of  the  thorax.     The  latter 


Fig.  23. — Aieas  of  deep  and  superficial  hepalic 
d  ulness. 


-■> 


Fig.  -4. — Areas  of  deep  and  superficial 
hepatic  dulness. 


in  the  midclavicular  line  corresponds  with  the  sixth  rib;  in  the  mid- 
axillary  line  with  the  eighth  rib,  and  posteriorly  with  the  tenth  rib.  Upon 
percussion  that  portion  of  the  liver  which  lies  in  relation  with  the  wall  of 
the  chest  yields  well-marked  dulness;  that  which  is  covered  by  the  inter- 
posed bonier  of  the  lung  modified  dulness.  The  former  is  spoken  ol  as  the 
area  of  superficial  hepatic  dulness,  the  latter  as  the  area  of  deep  hepatic 
dulness,  and  these  two  areas  together  constitute  the  area  of  hepatic  dulness. 
The  lower  anterior  margin  corresponds  in  the  midclavicular  line  with 
the  margin  of  the  ribs;  in  the  median  line  it  lies  slightly  above  a  horizontal 
line  midway  between  the  base  of  the  ensiform  cartilage  and  the  umbilh  us; 
about  the  left  parasternal  line  at  the  lower  border  of  the  sixth  rib;  in  the 
right  midaxillary  line  at  the  tenth  interspace;  and  at  the  spine  about  the 
level  of  the  eleventh  intercostal  space. 


36 


MEDICAL  DIAGNOSIS. 


The  interlobar  notch  lies  nearly  in  the  median  line.  The  thin  edge 
of  the  left  lobe  reaches  closely  to  the  midclavicular  line.  To  the  right  of 
the  right  midclavicular  line  the  lower  border  corresponds  approximately 
to  the  costal  margin.  In  aged  persons  the  liver  occupies  a  slightly  higher 
level;  in  children  it  is  large  in  proportion  to  the  size  of  the  body  and  extends 
higher,  displacing  the  apex  beat  of  the  heart  to  a  point  behind  the  fifth 
rib  or  in  the  fourth  interspace,  and  causing  the  lower  border  to  fall  below 
the  line  above  indicated  by  1  or  2  centimetres. 


The  GalUBladder  and  Extrahepatic  Bile  Passages. 

THE  GALL-BLADDER. 

This  membranous  sac  is  situated  in  a  fossa  in  the  base  of  the  liver. 
It  is  pear-shaped,  measuring  in  its  long  diameter  from  7  to  10  centimetres 
and  in  its  greatest  transverse  diameter  about  4  centimetres.  It  lies  ob- 
liquely, with  its  fundus,  which  projects  beyond  the  anterior  margin  of  the 

gland,  looking  downward,  forward, 
and  to  the  right.  There  is  often  a 
slight  notch  in  the  margin  of  the  liver 
at  this  point,  which  corresponds  to 
the  outer  border  of  the  right  rectus 
muscle  at  the  level  of  the  inner  edge 
of  the  ninth  costal  cartilage. 

THE  EXTRAHEPATIC  BILE 
PASSAGES. 

The  Cystic  Duct. — The  neck  of 
the  gall-bladder,  which  grows  gradu- 
ally narrower,  forms  a  double  curve 
like  the  letter  S,  and  then  becoming 
much  constricted  it  turns  abruptly 
downward  to  form  the  cystic  duct, 
which  runs  downward  and  to  the  left 
and  unites  with  the  hepatic  duct  to 
form  the  common  duct. 

The  Hepatic  Duct. — This  duct 
is  formed  by  the  union  of  a  right  and 
a  left  branch,  which  issue  from  the 
transverse  fissure  and  unite  at  an 
obtuse  angle.  Its  diameter  is  3  or  4 
millimetres  and  its  length  about  4 
centimetres.  It  unites  with  the  cystic 
duct  to  form  the  common  duct. 
The  Common  Bile  Duct;  Ductus  Communis  Choledochus. — This 
is  the  largest  of  the  bile  passages,  being  5  or  6  millimetres  in  width  and  6 
centimetres  or  more  in  length.  It  runs  downward  and  backward  to  the 
inner  and  posterior  wall  of  the  duodenum,  where,  uniting  with  the  pancre- 
atic duct  to  form  a  dilatation,  known  as  the  ampulla  of  Vater,  it  penetrates 
the  wall  of  the  duodenum  very  obliquely  in  the  course  of  its  middle  third. 


Fig.  25. — Position  of  fundus  of  gall-bladder. 


MEDICAL  TOPOGRAPHY. 


37 


.  Pathological  conditions  involving  the  ducts,  such  as  cholangitis  and 
gall-stone  disease,  do  not  direct]}'  give  rise  to  physical  signs,  but  they  cause 
serious  symptoms  and,  indirectly,  marked  physical  signs,  and  a  knowledge 
of  the  position  and  size  of  these  ducts  and  their  relations  to  each  other  is 
of  prime  importance  in  the  diagnosis  of  the  diseases  to  which  they  are  liable. 
The  weight  of  the  liver  and  its  direct  relationship  with  the  diaphragm 
render  it  to  a  high  degree  subject  to  the  influence  of  gravity  in  different 
postures  of  the  body,  as,  for  example,  the  erect  position  as  compared  with  the 
dorsal  decubitus,  and  to  the  influence  of  the  respiratory  movements.  Due 
allowance  for  these  changes  in  the  position  of  the  organ  is  to  be  made  in  its 
physical  examination. 

The  Pancreas. 

This  elongated,  flattened  gland  is  situated  deeply  in   the  abdominal 
cavity  directly  behind  the  stomach  and  at  the  level  of  the    first  lumbar 
vertebra.      The  larger  right  extremity  is  called  the  head  and  is  embraced 
by  the  curvature  of  the  duodenum.     Its  smaller  left 
extremity,  the  tail,  is  situated  in  a  slightly  higher  level  I 

than  the  head  and  reaches  to  the  spleen,  with  which  it  ,„  v>  .*w 

is  in  contact.  This  organ  varies  considerably  in  size, 
being  between  15  and  20  centimetres  in  length,  about 
4  centimetres  in  average  breadth,  and  about  2.5  centi- 
metres in  thickness.  It  extends  across  the  epigastric  T^' 
region  and  into  the  right  and  left  hypochondrium.  Its 
principal  duct  traverses  the  entire  length  of  the  gland  "^  j  fl 
and  in  association  with  the  common  bile  duct  enters 
the  duodenum  by  an  oblique  passage  through  its  wall. 
Its  great  depth  in  the  body  renders  it  as  a  rule  inac- 
cessible to  direct  physical  examination.  The  close 
relations  of  the  head  of  the  pancreas  with  the  portal 
vein,  the  inferior  vena  cava,  and  the  ductus  communis 
choledochus  are  of  clinical  importance,  since  malig- 
nant or  other  disease  attended  by  enlargement  of  that 
part  of  the  gland  constitutes  a  not  infrequent  cause 
of  oedema,  ascites,  or  persistent  jaundice. 


The  Spleen. 

This  soft,  vascular  organ  is  situated  in  the  left 
hypochondrium, opposite  the  ninth, tenth,  and  eleventh 
ribs,  and  in  the  posterolateral  portion  of  the  upper 
part  of  the  abdominal  cavity.  It  undergoes  consid- 
erable variation  in  size  in  health  and  may  be  enor- 
mously enlarged  in  disease.  It  is  irregularly  ovaJ  in 
shape,  its  upper  and  posterior  borders  being  rounded  and  thick,  ils  lower 
and  anterior  borders  sharp  and  the  latter  indented  by  two  or  more  notches. 
Its  convex  outer  surface  is  in  relation  with  the  inner  surface  qf  the  left 
side  of  the  diaphragm.  Its  concave  inner  surface  presents  a  vertical  fis- 
sure called  the  hilus,  and  is  in  relation  at  its  posterior  portion  with  the 


Pia.  26 


38  MEDICAL  DIAGNOSIS. 

suprarenal  capsule  and  the  upper  part  of  the  left  kidney,  and  at  its  ante- 
rior portion  with  the  stomach,  the  splenic  flexure  of  the  colon,  and  coils  of 
the  small  intestine.  Its  average  long  diameter  under  normal  conditions 
is  between  8  and  10  centimetres  and  it  cannot  be  felt  upon  palpation. 
Supernumerary  .spleens  are  not  uncommon. 

The  Kidneys. 

The  right  and  left  kidneys  are  deeply  seated  in  the  lumbar  region  in 
the  back  part  of  the  cavity  of  the  abdomen  and  behind  the  peritoneum, 
opposite  the  last  dorsal  and  the  first,  second,  and  sometimes  the  third 
lumbar  vertebrae.  The  position  of  the  right  kidney  is  slightly  lower  than 
that  of  the  left.  Each  kidney  is  about  9  centimetres  long,  6.5  centimetres 
in  width,  and  3  centimetres  in  thickness,  the  left  being  usually  longer  and 
thinner  than  the  right.  Their  oblong,  rounded  concavo-convex  shape  is 
characteristic.  The  convexity  of  each  is  directed  outward  and  backward; 
the  concavity  inward  and  slightly  forward.  '  Near  the  middle  of  the  con- 
cave surface  is  a  longitudinal  fissure  or  hilus  at  which  the  vessels  and 
nerves  enter  or  emerge  and  the  ureter  arises.  This  excretory  duct  expands 
within  the  hilus  into  the  pelvis  of  the  kidney,  from  which  arise  three  or 
sometimes  two  funnel-shaped  spaces  which  subdivide  into  a  number  oi 
smaller  tubes  called  calices  or  infundibula,  similarly  funnel-shaped  but 
into  which  the  papillae  of  the  kidney  project.  The  kidneys  are  supported 
by  the  vessels  and  the  perirenal 'fat.  The  right  kidney  is  in  relation  with 
the  duodenum  and  colon  in  front  and  the  liver  above;  the  left  with  the 
spleen  above  and  colon  anteriorly.  Both  lie  against  the  corresponding 
pillar  of  the  diaphragm,  the  anterior  layer  of  the  lumbar  fascia,  and  the 
psoas  muscle.  The  deep  situation  of  the  kidneys  and  the  thick  layers  of 
muscles  against  which  they  rest,  embedded  in  a  layer  of  fat  behind,  render 
them  under  normal  circumstances  inaccessible  to  the  ordinary  methods 
of  physical  examination.  When  they  are  displaced  or  enlarged  they  present 
characteristic  physical  signs.  The  suprarenal  bodies  are  also  beyond  the 
reach  of  the  usual  procedures  of  physical  diagnosis.  The  ureters  descend 
from  the  hilus  of  each  kidney  to  enter  the  bladder  at  its  base.  When 
dilated — hydronephrosis — they  form  characteristic  abdominal  tumors. 

The  Bladder. 

When  empty  this  organ  lies  below  the  symphysis  pubis;  when  dis- 
tended it  gives  rise  to  a  globular  area  of  dulness  in  the  hypogastrium. 
In  some  neglected  cases  of  urethral  stricture  or  enlarged  prostate  an  over- 
distended  bladder  forms  a  large  fluctuating  tumor,  reaching  as  high  as  the 
umbilicus  and  inclining  somewhat  more  to  one  side  of  the  median  line 
than  to  the  other. 


III. 

THE  EXAMINATION  OF  THE  PATIENT  AND  CASE-TAKING. 

Case=Taking. 

An  accurate  knowledge  of  the  facts  in  the  case  constitutes  the  first 
requisite  to  a  diagnosis.  Those  relating  to  the  medical  life  of  the  patient 
and  his  illness  up  to  the  time  of  his  coming  under  observation  are  known 
as  the  history  of  the  case,  or  the  anamnesis;  those  relating  to  his 
immediate  circumstances,  alike  subjective  or  objective,  are  described 
under  the  heading  present  condition,  or  status  pr.k>i;x>. 

The  examination  to  ascertain  the  necessary  facts  should  be  conducted 
in  an  orderly  and  systematic  manner.  Time  is  thus  saved,  a  general  sur- 
vey of  the  clinical  phenomena  made,  and  those  of  chief  importance  brought 
into  contrast  and  proper  relation  with  those  of  subordinate  value.  Data 
not  otherwise  obvious  are  brought  to  light  and  the  chances  of  oversight 
minimized.  Vague  and  pointless  inquiries  are  omitted.  The  interrogation 
is  precise  and  explicit.  Above  all,  leading  questions  are  to  be  avoided. 
Running  comments  in  the  presence,  of  the  patient  produce  an  especially 
unfavorable  effect.  Tact  and  patience  are  necessary.  An  examination 
tim>  conducted  lias  a  favorable  influence  upon  the  patient,  especially  in 
chronic  and  difficult  cases,  and  always  inspires  confidence.  The  investiga- 
tion should  not  be  unduly  extended  or  minute.  The  examination  of  an 
experienced  and  thoroughly  trained  clinician  stands  in  striking  contrast 
to  the  vague  and  unsystematic  questions  of  the  beginner.  On  the  other 
hand,  the  inquiry  may  be  too  concise  and  brief.  The  former  met  hod  has 
been  spoken  of  as  the  extensive,  the  latter  as  the  intensive.  The  middle 
course  is  the  best. 

There  are  two  principal  modes  of  case-taking,  the  synthetic  and  the 
analytic. 

THE  SYNTHETIC  METHOD. 

In  the  synthetic,  sometimes  spoken  of  as  the  historical  met  hod.  the 
inquiry  begins  with  the  history  of  the  patient,  rather  than  with  his  present 
condition.  His  place  of  birth,  age,  social  state,  occupation,  previous  dis- 
eases, habits,  hereditary  and  constitutional  tendencies  are  first  ascertained, 
then  follows  an  investigation  into  the  beginning  and  progress  of  the  presenl 
illness.  All  this  constitutes  the  anamnesis.  The  status  prsesens  is  then 
considered.  The  condition  of  the  several  physiological  systems,  the  diges- 
tive, the  circulatory,  the  respiratory,  the  genito-urinary,  the  nervous,  and 
so  on,  being  carefully  inquired  into  in  regular  order.  Finally,  the  symp- 
toms and  signs  referable  to  the  organs  or  structures  especially  affected 
are  carefully  studied.  The  next  step  in  the  process  is  the  diagnosis,  upon 
which  the  prognosis,  treatment  and  general  management  of  I  he  case  depend. 
Case-taking  by  this  method  follows  the  natural  order.     It  is  scientific  and 

39 


40  MEDICAL  DIAGNOSIS. 

useful  in  obscure  cases.  The  chief  objections  to  it  are  the  time  it  consumes 
and  the  fact  that  in  the  progress  of  the  inquiry  unnecessary  attention  must 
be  given  to  facts  which  are  found  later  to  have  little  or  no  bearing  upon 
the  patient's  present  condition. 

THE  ANALYTICAL  METHOD. 

In  the  analytical  method  the  order  of  procedure  is  reversed.  The 
principal  symptoms  are  taken  as  the  point  of  departure  for  the  investiga- 
tion. The  organ  or  region  to  which  these  symptoms  are  referred  is  exam- 
ined by  the  proper  diagnostic  measures.  The  general  condition  of  the 
patient,  his  fades,  the  state  of  nutrition  of  his  body,  his  posture,  his  move- 
ments, are  carefully  observed;  meanwhile  he  is  questioned  as  to  the  dura- 
tion and  progress  of  the  present  illness  and  an  inquiry  is  made  into  such 
facts  in  his  previous  history  and  antecedents  as  may  bear  upon  the  case. 
The  clinical  study  is  then  extended,  the  condition  of  the  other  organs  inves- 
tigated, the  history  of  the  case  more  systematically  reviewed,  an  opinion 
formed  as  to  whether  the  malady  is  general  or  local  and  a  diagnosis  reached. 
This  is  the  plan  commonly  pursued  in  ordinary  professional  work  where  the 
data  are  sufficient  for  a  diagnosis  by  the  direct  method,  and  is  available 
in  all  cases  except  those  where  the  symptoms  are  obscure  and  ill  defined. 

QUESTIONS. 

Great  care  is  necessary  in  formulating  questions.  It  is  not  sufficient 
to  ask  the  patient  if  the  present  illness  began  with  a  chill  and  be  content 
with  an  affirmative  answer.  Many  patients  regard  the  transient  shivering 
which  so  often  marks  the  onset  of  an  acute  febrile  disease  as  a  chill,  whereas 
it  is  a  very  different  matter  from  the  prolonged  and  intense  rigor  that 
attends  the  onset  of  pneumonia  or  the  malarial  paroxysm.  The  phj'sician 
must  be  on  his  guard  also  in  regard  to  statements  made  by  patients  or  their 
friends  concerning  their  previous  illnesses.  Very  often  such  diagnoses  are 
popular  rather  than  professional,  and  questions  must  be  so  framed  as  to 
determine  their  accuracy.  Accounts  of  influenza,  malaria,  catarrh  of  the 
stomach,  rheumatism,  and  the  like  cannot  be  accepted  without  close  inves- 
tigation into  the  symptoms,  course  and  duration  of  the  illnesses  referred  to. 
The  "stomach  cough"  and  "malaria"  of  the  consumptive  are  familiar  to 
all  practitioners.  In  the  matter  of  hereditary  and  family  tendencies  to 
disease  the  examination  must  be  conducted  with  great  care.  It  is  no 
uncommon  thing  for  patients,  even  those  who  are  well  informed  and  intel- 
ligent, to  deny  the  existence  of  malignant  disease,  chronic  nephritis,  a 
tendency  to  tuberculosis,  and  the  like,  when  careful  inquiry  or  the  inde- 
pendent statements  of  their  friends  render  the  occurrence  of  these  diseases 
in  the  family  in  the  highest  degree  probable.  A  patient  will  affirm  that 
no  case  of  consumption  has  ever  occurred  in  his  family,  and  upon  cautious 
questioning  admit  that  his  father  or  mother  or  other  near  relative  suffered 
from  chronic  cough,  abundant  expectoration,  blood-spitting,  and  progressive 
emaciation.  An  epileptic  will  deny  the  occurrence  of  nervous  diseases, 
and  subsequently  admit  that  near  relations  have  presented  the  symptoms 


EXAMINATION  OF  PATIENT  AND  CASE-TAKING.  41 

of  hysteria  or  neurasthenia  or  been  insane.  Patients  very  often  withhold 
in  the  presence  of  a  nurse  or  other  attendant  important  facts  that  they 
willingly  communicate  to  the  physician  alone. 

RECORDS. 

Records  should  be  kept  in  private  as  well  as  in  hospital  and  dispensary 
practice.  How  full  these  should '  be  will  depend  upon  the  physician's 
estimate  of  the  importance  of  the  individual  case.  Their  preparation 
demands  close  attention,  concise  statements,  and  accuracy.  They  consti- 
tute a  permanent  store  of  professional  experience  for  future  reference  and 
study.  They  are  of  great  value  in  the  review  of  the  history  of  patients 
previously  seen,  as  an  aid  in  comparing  one's  personal  observations  with 
those  of  the  profession  at  large,  in  the  preparation  of  articles  for  publica- 
tion, and  not  infrequently  as  bearing  upon  medico-legal  cases.  They  should 
be  preserved  in  accordance  with  a  uniform  plan  in  books  prepared  for  the 
purpose,  or  preferably  upon  cards  of  convenient  dimensions  arranged  in 
cabinets,  in  the  same  manner  as  the  index  catalogues  used  in  libraries. 
Uniformity  is  important.  It  prevents  the  oversight  of  significant  facts 
and  facilitates  the  comparison  of  cases.  The  following  scheme  is  suggestive; 
it  may  be  modified  in  accordance  with  individual  views: 

SCHEME  FOR  CASE  RECORDS. 

Case  record  number Diagnosis Revise Result 

Admitted Discharged (In  hospital  patients). 

Date  of  examination 

Name Age Sex Race Place  of  birth Present 

abode Former  occupation Present  occupation Social  state 

Married,  single,  widowed. 

Anamnesis. 

1.  Family  History:  Hereditary  tendencies;  health  of  parents,  brothers  and  sisters; 
deaths  in  family — cause,  age. 

2.  Personal  History:  (a)  Diseases  of  childhood;  (b)  menstruation;  (c)  preg- 
nancies, miscarriages,  date  of  last  confinement:  (d)  previous  illnesses  or  injuries;  (e)  habits 
— regularity  of  meals,  kind  of  food,  method  of  eating;  bowels;  sleep;  habitual  or 
occasional  physical  or  mental  overexertion;   tobacco;   alcohol;   narcotics. 

:;.  Prebeni  Illness:  (a)  Date  of  onset;  supposed  exciting  cause;  exposure  to  con- 
tagion;  prodromes;  initial  symptoms;  course  of  the  attack;  previous  treatment,  (b) 
Antecedent  derangements  of  health  not  amounting  to  positive  disease,  appetite,  pain, 
cough,  disturbances  of  sleep,  headache,  etc. 

Stati  -.     I'll  i  - 

A.  General  Appearance:  Expression,  height  and  weight,  musculature,  bony 
structure,  panniculus  ailiposus;  posture  in  bed;  movements,  ir;iit  ami  station  oul  ol  bed; 
temperature;  pulse;  respiration;  color  and  condition  of  the  skin;  perspiration;  oedema; 
eruptions;  psychical  condition;  sensations  ami  complaints;  delirium;  convulsions 
stupor;   coma. 

B.  Particular  Phenomena:  Symptoms  and  signs  relating  to  special  structures, 
organs  and  functions. 

1.  The  Digestive  Apparatus:  Inspection  of  the  mouth,  tongue  and  gums;  tonsils 
and  pharynx;  palpation  of  the  abdomen,  its  form  and  contour,  visible  peristalsis,  tender- 
Oese  upon  pressure,  resistance,  tumors;  percussion  ami  palpation  of  the  stomach  ami 
intestines,  liver,  gall-bladder,  spleen;    inspection  of  vomited  matters  ami  fa  I 

2.  The  Circulatory  Apparatus:  Inspection  and  palpation  of  the  cardiac  area;  visible 
and  palpable  pulsation;  thrill;  precordial  prominence;  position  of  the  apex;  percussion 
and  auscultation  of  the  heart;    the  pulse-frequency,  rhythm,  fulness,   tension;    condition 


42  MEDICAL  DIAGNOSIS. 

of  walls  of  arteries;  venous,  pulsation;  capillary  pulse;  liver  pulsation;  auscultation  of 
the  arteries  and  veins;  arterial  pressure,  maximal  and  minimal;  examination  of  the 
blood,  etc. 

3.  The  Respiratory  Apparatus:  Nose,  mouth,  and  larynx;  cough  and  expectora- 
tion ;  chest  and  lungs — character  of  the  respiration,  dyspnoea,  stridor,  Cheyne-Stokes 
respiration;  contour  of  the  thorax;  local,  lateral  or  bilateral  retraction  or  expansion; 
respiratory  excursus;  fremitus;  local  and  general  physical  signs  obtained  by  percussion, 
auscultation,  and  mensuration  ;  the  cyrtometer. 

4.  The  Genito-Urinary  Apparatus:  Palpation  of  the  kidneys  and  bladder  ;  percussion 
of  the  bladder ;  retention  of  urine ;  suppression;  frequency  of  micturition ;  pain;  quantity 
of  urine;  total  amount  for  twenty-four  hours;  disturbance  at  night;  chemical  and  micro- 
scopic examination  of  the  urine;  sexual  organs;  the  prostate. 

5.  The  Nervous  System:  Intelligence;  mental  state;  subjective  sensations;  sleep, 
gait,  station,  reflexes,  tremor,  convulsions,  spastic  conditions,  paralysis;  aphasia  and 
other  disorders  of  speech ;  derangements  of  sensation ;  the  organs  of  special  sense. 

6.  The  Osseous  System — Bones  and  Joints:  General  and  local  changes  in  the  skeleton; 
cranium,  spine,  thorax,  pelvis,  long  bones,  extremities;  striking  deformities;  the  joints; 
size  and  shape,  color,  pain,  degree  of  impairment  of  function,  fixation,  disintegration. 

7.  The  Tegumentary  System:  Itching,  burning,  tension,  pain,  inflammatory  phe- 
nomena :  presence  and  character  of  eruptions,  macular,  papular,  vesicular,  pustular ; 
uniformity;  polymorphism;  hypertrophy  and  atrophy;  cicatrices;  pigmentary  changes*; 
animal  and  vegetable  parasites;  subcutaneous  structures;  enlargement  or  atrophy  of 
thyroid  body;   lymph  nodes;  constitutional  disturbances. 

Diagnosis;  Prognosis;  Treatment;   Subsequent  observations. 

The  results  of  special  clinical  and  laboratory  examinations  are  to  be 
incorporated  under  the  appropriate  headings.  Among  these  are  rhinoscopic 
and  laryngoscopic,  ophthalmoscopic  and  otoscopic  examinations;  hemato- 
logic investigations ;  the  chemical  and  microscopic  examination  of  the  gas- 
tric contents,  vomited  material,  and  the  stools ;  of  expectorated  matters ; 
bacteriologic  examinations  of  the  blood,  sputum,  secretions,  exudates,  etc., 
by  the  methods  of  staining,  culture,  and  inoculation ;  examination  of  the 
rectum  by  the  finger,  the  speculum,  and  by  inflation ;  cystoscopy ;  special 
examination  of  the  genital  organs  in  both  sexes,  examination  of  the  fluids 
obtained  by  exploratory  puncture,  and  examination  by  the  X-rays,  etc. 

In  febrile  cases  temperature  charts  should  be  preserved  with  the 
records,  and  superficial  deformities,  as  swelling  or  retraction,  as  well  as 
changes  in  the  viscera  revealed  by  the  various  methods  of  diagnosis,  may 
be  indicated  upon  outline  clinical  diagrams  and  incorporated  in  the  notes. 
Changes  of  contour,  glandular  enlargements  and  topographical  lesions, 
such  as  local  consolidations  and  cavity  formation  in  the  lungs,  cardiac 
dilatation  or  hypertrophy,  pleural  and  pericardial  effusions  and  the  result- 
ing displacement  of  adjacent  viscera,  enlargement  of  the  liver  and  spleen, 
dilatation  of  the  stomach  and  displacement  of  the  abdominal  organs  may 
in  this  manner  be  more  or  less  accurately  delineated.  The  location  of  tumors, 
circumscribed  exudates,  and  other  foci  of  infection  may  also  be  indicated,  and 
in  the  case  of  the  nervous  system  the  extent  and  distribution  of  areas  of 
disturbance  of  sensation  and  other  phenomena. 

Some  further  explanation  of  the  bearing  of  the  facts  noted  in  the 
anamnesis  upon  the  mental  processes  by  which  a  diagnosis  is  reached  may 
be  of  service  to  the  student. 

Age. — The  age  is  important.  Each  period  of  life  has  its  peculiar 
susceptibility  to  morbid  influences.  In  the  new-born,  congenital  defects, 
the  results  of  the  accidents  of  parturition,  diseases  arising  from  faulty 
management  of  the  cord,  those  directly  transmitted  from  the  mother, 
and  those  produced  by  improper  diet  and  unhygienic  surroundings  are 


EXAMINATION  OF  PATIENT  AND  CASE-TAKING 


43 


common.  In  childhood,  anatomical  peculiarities  of  the  growing  organism 
and  the  sensitiveness  of  physiological  processes  to  external  influences  give 
rise  to  special  predispositions  to  disease.  Thus,  the  ready  proliferation 
of  the  lymph  tissues  explains  the  frequent  occurrence  of  respiratory 
obstruction  in  the  nasopharynx  from  adenoid  hypertrophy,  while  the 
narrowness  of  the  larynx  accounts  for  the  gravity  of  catarrhal  and  infective 
processes  involving  that  organ,  and  the  great  vascularity  and  rapid  over- 
growth of  the  epithelium  of  the  bronchi  when  irritated  explain  the  peculiar 
liability  of  children  to  bronchitis  and 
bronchopneumonia.    In  the  instability 


In..  J7. — Clinical  diagram. 


Clinical  diagram. 


of  the  nervous  system  in  children  we  find  a  ready  explanation  <>r  their 
liability  to  fever,  its  high  range  and  rapid  find  nations,  and  to  various 
reflex  disturbances,  and  in  the  absence  of  acquired  immunity,  an  explana- 
tion of  the  wide  prevalence  among  them  of  the  transmissible  infections,  as 

the  exanthemata,  which  are  spoken  of  as  the  diseases  of  childhood.  In 
adolescence,  hereditary  predispositions  begin  to  show  themselves,  as  in 
the  occurrence  of  tuberculosis  and  of  epilepsy  or  other  nervous  affections. 
The  late  sequels  of  infantile  diseases,  as  chronic  valvular  trouble  following 
rheumatic  endocarditis,  or  chronic  nephritis  subsequent  to  scarlatina, 
often  now  appear.  Changes  in  the  environment  of  the  individual  subject 
him  to  special  pathogenic  influences,  and  pleurisy  with  or  without  effusion, 


44  MEDICAL  DIAGNOSIS. 

pneumonia,  and  enteric  fever  are  common.  The  middle  period  of  life  is 
especially  prone  to  diseases  that  result  from  occupation,  examples  of  which 
are  lead  intoxication,  caisson  disease,  and  scrivener's  palsy,  to  those  which 
result  from  the  habitual  use  of  narcotics,  as  gastric  catarrh,  hepatic  cir- 
rhosis, and  alcoholic  neuritis,  to  those  resulting  from  the  stress  of  life  and 
anxiety,  among  which  may  be  named  cardiac  hypertrophy,  the  neuras- 
thenias and  other  nervous  diseases  and  insanity.  It  is  in  this  period  that 
hereditary  and  acquired  tendencies  to  sclerotic  changes  in  the  vessels 
and  in  the  nervous  system  begin  to  develop  and  that  diabetes  and  the 
paroxysms  of  gout  commonly  first  show  themselves.  Later  in  life  the 
indications  of  progressive  degenerations  become  more  marked.  The 
wrinkled  skin,  the  failing  sight  and  hearing,  the  feeble  heart,  winter  cough, 
and  renal  inadequacy  are  the  indications  of  sclerotic  and  nutritive 
changes  which  are  more  apparent  in  the  rigid,  tortuous,  or  atheromatous 
superficial  arteries.  This  is  especially  the  period  of  apoplexy,  chronic 
bronchitis,  diabetes,  cystitis  from  hypertrophied  prostate,  Parkinson's 
disease  and  the  special  infections,  erysipelas  and  pneumonia,  which  are 
frequently  terminal  events.  In  general  terms  the  evolution  of  life  is 
the  period  of  infections,  the  involution  the  period  of  degenerations; 
but  in  pathology  age  cannot  be  measured  by  years,  and  the  signifi- 
cant saying  that  "a  man  is  as  old  as  his  arteries"  has  become  a  modern 
medical  aphorism. 

Physiological  Epochs. — The  epochs  of  life  are  also  marked  by  special 
liability  to  disease.  Thus  at  the  first  dentition  nutritional  diseases  and 
gastro-intestinal  troubles  are  common;  at  puberty,  chlorosis  and  hysteria; 
at  the  menopause,  hysteria,  obesity,  and  arthritis  deformans.  It  is  to  be 
noted,  however,  that  the  maladies  of  these  physiological  epochs  are  not 
always  the  direct  result  of  functional  changes,  but  usually  the  outcome  of 
previous  morbid  conditions  or  tendencies. 

Sex. — Sex  is  likewise  important.  In  early  and  advanced  life  the  sexes 
are  equally  liable  to  disease.  Women  between  the  age  of  puberty  and  the 
menopause  are  exposed  to  the  danger  of  many  accidents  and  diseases  peculiar 
to  the  anatomical  and  physiological  development  connected  with  the  sexual 
life  and  child-bearing.  Consideration  of  these  matters  properly  belongs 
to  gynaecology  and  midwifery.  Sedentaiy  living,  the  monotony  of  the 
household,  and  depressing  moral  influences  also  act  as  causes  of  disease 
in  women.  Hysteria,  neurasthenia,  and  special  forms  of  insanity  occur. 
These  peculiarities  do  not,  however,  carry  with  them  an  exemption  from 
other  pathogenic  influences,  and  among  the  peasantry  of  those  countries 
where  the  women  largely  engage  in  the  same  occupations  as  the  men  they 
are,  in  addition  to  their  own  peculiar  disorders,  equally  liable  to  most  of  the 
maladies  which  affect  the  other  sex  and  nearly  to  the  same  extent.  In  more 
enlightened  districts  and  among  the  upper  classes  of  society  women  escape 
many  risks  of  disease  to  which  men  are  exposed.  In  the  male  sex  occupa- 
tion, exposure,  the  strenuous  life,  and  self-indulgence  are  common  causes 
of  disease,  hence  the  more  frequent  occurrence  of  plumbism,  farcy,  pneu- 
monia, chronic  arthritis,  gout,  tabes,  and  alcoholism.  As  a  consequence, 
arteriosclerosis  and  atheroma  are  more  marked  in  men  than  in  women 
at  advanced  age. 


EXAMINATION  OF  PATIENT  AND  CASE-TAKING.  45 

Race  and  Nationality. — These  points  demand  consideration  in  the 
anamnesis.  The  peculiar  liability  of  the  Hebrew  to  diabetes  and  neuras- 
thenia; of  the  negro  and  mulatto  to  tuberculosis,  and  the  relative  immunity 
of  the  former  to  malaria  and  yellow  fever;  the  prevalence  of  beriberi 
among  the  oriental  races,  of  leprosy  in  Scandinavia,  the  Sandwich  Islands, 
and  the  West  Indies;  and  the  frightful  ravages  of  tuberculosis,  syphilis, 
and  alcoholism  among  the  Indians  of  North  America  are  well-known  facts. 

Nativity.  —  The  place  of  birth  and  residence  frequently  shed  light 
upon  an  obscure .  case,  as  in  ill-defined  malaria,  the  malarial  cachexia, 
goitre,  cretinism,  and  leprosy.  A  knowledge  of  the  district  or  locality  of 
the  patient's  present  residence,  the  situation  of  his  home,  its  sanitary 
conditions  and  surroundings,  the  source  of  the  water  supply,  and  the 
disposition  of  the  sewage   may  shed  light  upon  the  diagnosis. 

Occupation. — The  occupation  of  the  patient  demands  careful  investi- 
gation. The  habitual  over-use  of  certain  muscles,  and  exposure  to  particular 
irritants  or  poisons  or  an  atmosphere  laden  with  minute  mineral  or  metallic 
particles  or  chemicals,  or  to  infections  peculiar  to  certain  crafts,  cause  defi- 
nite diseases.  Examples  of  such  affections  are  writer's  cramp,  anthracosis 
or  miner's  consumption,  chronic  phosphorus  poisoning  among  workmen 
engaged  in  the  manufacture  of  matches,  malignant  pustule  or  wool- 
sorter's  disease,  and  glanders.  It  is  necessary  to  inquire  carefully  into 
former  occupations  as  well  as  the  present;  thus  chronic  bronchitis  with 
bronchiectasis  may  have  had  its  origin  in  the  inhalation  of  the  dust  caused 
by  stone-cutting — an  occupation  long  abandoned  by  the  patient.  In  those 
occupied  in  professional  or  literary  work  functional  derangements  of  the 
stomach,  constipation,  and  insomnia  are  common.  Even  amusements 
may  be  the  cause  of  disease,  as  in  the  golfer's  back  and  the  heart-strain  of 
the  athlete. 

Heredity.  —  The  family  history  has  a  very  important  bearing  upon 
the  diagnosis,  especially  in  chronic  diseases.  It  is  difficult  to  frame  a 
satisfactory  definition  for  heredity,  but  we  know  that  traits  and  lineaments 
are  transmitted  from  parents  to  children  through  the  generations,  and 
we  occasionally  observe  in  a  son  who  has  his  mother's  features  some  trick 
of  expression  that  makes  his  resemblance  to  his  father  for  the  moment 
almost  startling.  So  too  are  transmitted  from  one  generation  to  another 
tissue  peculiarities  and  constitutional  tendencies  to  disease.  The  inquiry 
into  the  family  history  must  be,  as  has  been  pointed  out  in  a  previous 
paragraph,  conducted  with  tact  and  caution.  Blunt  inquiries  in  regard 
to  "consumption,"  "cancer,"  "Blight's  disease,"  or  "insanity"  irritate 
the  patient  and  usually  elicit  vague  replies  or  absolute  denials.  A  patient 
should  be  asked  if  his  parents  are  living  and  in  good  health;  if  not  in  good 
health,  the  symptoms  and  duration  of  the  illness;  if  dead,  the  cause  <>l' 
death  and  the  age  at  which  it  occurred.  He  should  be  questioned  as  to 
the  number  of  his  brothers  and  sisters,  their  health,  and  the  cause  of  any 
deaths  that  may  have  occurred  among  them.  It  is  very  important  to  learn 
whether  or  not  deaths  in  the  family  have  been  the  result  of  acute  or  chronic 
disease.  The  inquiry  may  be  extended  to  the  preceding  generation  and 
collateral  brunches  of  the  family.  Diseases,  it  is  true,  are  conveyed  by 
hereditary  transmission,  but  their  number  is  comparatively  few.     Haemo- 


46  MEDICAL  DIAGNOSIS. 

philia  is  a  striking  example.  Syphilis  is  very  commonly  thus  transmitted. 
When  the  mother  has  contracted  an  acute  infection,  as  measles  or  enteric 
fever,  the  child  may  be  born  during  the  period  of  incubation  or  with  the 
symptoms  of  the  disease  already  manifest.  A  number  of  nervous  diseases 
are  clearly  hereditary.  As  examples  may  be  mentioned  progressive  mus- 
cular atrophy,  hereditary  chorea,  Friedreich's  ataxia,  and  migraine.  The 
definite  symptoms  may  not  show  themselves  for  some  years  after  birth, 
in  some  cases  not  until  adult  life.  Much  more  commonly  it  is  the  pre- 
disposition that  is  transmitted.  This  is  especially  the  case  in  tuberculosis. 
The  peculiar  exposure  of  the  young  infant  to  infection  from  a  tuberculous 
mother  and  the  length  of  time  that  the  tuberculous  lesions  in  many  in- 
stances remain  localized  render  it  in  the  highest  degree  probable  that  the 
predisposition  to  tuberculosis  rather  than  the  disease  itself  is  hereditary. 
This  view  is  confirmed  by  the  results  of  pathological  and  bacteriological 
investigations.  The  direct  transmission  of  tuberculosis  from  the  mother 
to  the  foetus  in  the  human  being  is  of  uncommon  occurrence.  The  doc- 
trine of  the  direct  hereditary  transmission  of  tuberculosis,  so  long  enter- 
tained but  now  fortunately  abandoned,  was  a  stumbling  block  in  the  way 
of  the  recognition  of  the  infectious  character  of  this  disease.  That  the 
predisposition  rather  than  the  disease  is  hereditary  is  also  true  of  cancer. 
The  occasional  occurrence  of  chronic  Bright's  disease  in  nearly  every 
member  of  a  family  in  two  or  three  generations,  usually  first  showing  itself 
in  adolescence  or  early  adult  life,  must  be  attributed  to  hereditary  defects 
of  the  renal  and  vascular  tissues,  while  faults  of  metabolism,  the  constitu- 
tional tendency  to  which  is  transmitted  from  father  to  son,  bear  a  direct 
etiological  relation  to  gout  and  its  associated  cardiovascular  and  renal 
changes.  The  development  of  forms  of  insanity  in  successive  generations 
of  a  family,  usually  at  the  physiological  epochs  of  life,  often  not  until  late 
middle  age,  must  likewise  be  attributed  to  hereditary  defects  of  nervous 
and  mental  organization.    - 

A  further  peculiarity  in  regard  to  the  hereditary  transmission  of 
disease  is  to  be  found  in  its  diverse  manifestations  among  various  members 
of  a  family.  The  radical  defect  or  susceptibility  may  find  expression  in 
pathological  conditions  which  are  allied  but  which  have  wholly  different 
symptoms.  Thus  the  tendency  to  deranged  metabolism  and  arteriosclerosis 
may  in  one  show  itself  in  contracted  kidney  and  hypertrophied  heart; 
in  another  in  disease  of  the  aorta  or  angina  pectoris;  in  a  third  in  gout, 
renal  calculus  and  gravel,  or  yet  again  in  early  cerebral  hemorrhage  or 
thrombosis.  The  neuropathic  constitution  may  manifest  itself  in  one 
member  of  a  family  in  forms  of  neuralgia,  neurasthenia,  or  hysteria;  in 
another  in  the  development  of  epilepsy,  and  in  a.  third  in  the  guise  of 
hypochondriasis  or  insanity.  The  family  susceptibility  to  certain  infec- 
tions may  reveal  itself  in  different  individuals  in  recurrent  attacks  of 
tonsillitis  or  rheumatism,  chorea  or  chronic  valvular  disease;  or  the  sus- 
ceptibility to  tuberculosis,  on  the  one  hand  in  pulmonary  consumption, 
on  the  other  in  tuberculosis  of  the  bones  and  joints  or  glandular  disease, 
or  finally  in  the  implication  of  the  meninges,  pleura,  or  peritoneum. 

Immunity  may  be  transmitted  by  inheritance  as  well  as  the  pre- 
disposition to  disease.     There  are  families  and  individuals  who  possess  a 


EXAMINATION  OF  PATIENT  AND  CASE-TAKING.  47 

remarkable  natural  immunity  against  the  exanthemata.  This  is  espe- 
cially true  in  regard  to  scarlet  fever.  When  we  consider  the  wide 
prevalence  of  pulmonary  tuberculosis  and  the  diffusion  of  its  cause  in  the 
centres  of  population  and  certain  districts  and  houses,  and  the  fact  that  so 
large  a  proportion  of  individuals  and  families  constantly  exposed  to  the 
inhalation  of  an  atmosphere  containing  the  tubercle  bacilli  escape  the 
disease,  the  common  existence  of  a  natural  immunity  which  is  frequently 
transmitted  by  inheritance  becomes  evident.  The  predisposition  to  tuber- 
culosis is  far  less  general  than  that  to  scarlatina  and  measles.  The  occur- 
rence of  personal  peculiarities  and  morbid  tendencies  in  an  individual 
which  were  not  manifested  in  his  parents  but  existed  in  their  ancestors  is 
known  as  atavism.  In  rare  instances,  and  especially  in  cases  of  nervous 
disease  and  insanity,  this  condition  is  important  in  the  anamnesis.  Curi- 
ous facts  in  regard  to  the  duration  of  life  are  occasionally  observed. 
There  are  families  in  which  in  successive  generations  few  members  survive 
the  early  middle  period  of  life.  In  such  instances  death  is  very  often 
due  to  an  acute  disease  not  always  the  same.  On  the  other  hand,  all  the 
members  of  certain  families  reach  an  advanced  age,  the  exceptions  being 
where  death  is  due  to  accident  or  violence. 

Medical  History. — The  personal  history  is  essential  to  a  diagnosis 
in  the  broad  sense.  A  knowledge  of  the  significant,  facts  in  the  past  life 
of  the  patient  may  clear  up  a  doubtful  case.  The  present  disease  may  be 
a  late  sequel  of  some  previous  illness,  as  bronchitis  or  emphysema  after 
whooping-cough,  or  an  obscure  manifestation  of  one  of  the  exanthemata 
which  the  patient  escaped  in  childhood,  as  scarlatina  in  the  adult  with 
fever  of  moderate  intensity  and  an  irregular  patchy  eruption,  or  it  may 
be  the  expression  of  a  peculiar  constitutional  susceptibility,  as  tonsillitis, 
rheumatic  fever,  or  chorea,  from  which  the  patient  has  suffered  on  previous 
occasions.  In  this  connection  it  is  to  be  borne  in  mind  that  many  of 
the  acute  infectious  diseases,  and  especially  the  exanthemata,  result  in 
an  acquired  immunity  which  usually  lasts  throughout  life,  hence  second 
attacks  are  exceedingly  infrequent,  while  the  immunity  conferred  by  other 
infections,  for  example  rheumatic  fever,  erysipelas,  croupous  pneumonia, 
and  diphtheria,  is  incomplete  and  of  limited  duration,  so  that  many  individ- 
uals suffer  from  repeated  attacks  of  these  diseases.  In  acute  febrile  attacks 
and  in  the  presence  of  epidemics  careful  inquiry  as  to  exposure  to  the 
contagion  must  be  made.  The  period  of  incubation  and  the  occurrence  of 
prodromal  symptoms  are  to  be  taken  into  consideration.  In  women 
abnormal  menstruation,  the  accidents  and  diseases  of  pregnane)',  t  he  occur- 
rence of  miscarriages,  too  frequent  child-bearing  and  prolonged  lactation 
may  be  the  cause  of  serious  impairment  of  health  or  of  actual  disease. 
These  matters  must  be  carefully  inquired  into.  In  exceptional  cases, 
especially  in  aggravated  and  intractable  functional  nervous  diseases,  it 
becomes  necessary  to  inquire  more  closely  into  the  sexual  life  of  the  patient. 
The  investigation  must  be  conducted  with  great  delicacy  and  discretion. 
The  part  played  by  vicious  practices  and  excesses  in  the  production  of  such 
diseases  must  be  ascertained.  It  is  necessary  also  to  learn  whether  or  not 
the  patient  has  suffered  from  venereal  infection,  the  date  of  its  occurrence, 
the  nature,  character,  and  duration  of  the  primary  symptoms,  the  presence 


48  MEDICAL  DIAGNOSIS. 

or  absence  of  secondary  lesions,  and  the  treatment.  Gonorrhoea  is  not 
always  merely  a  local  affection.  The  frequency  with  which  it  is  followed 
by  stricture  is  well  known,  but  the  symptoms  of  the  latter  condition  may 
first  show  themselves  after  the  lapse  of  years.  Local  abscess  formation, 
acute  and  chronic  cystitis  and  pyelitis  also  occur.  The  immediate 
recognition  of  the  specific  nature  of  gonorrhoeal  ophthalmia,  whether  in 
the  new-born  or  in  the  adult,  is  a  matter  of  overwhelming  importance.  The 
diagnosis  of  many  a  case  of  disabling  and  stubborn  arthritis  is  made 
clear  by  a  knowledge  of  gonorrhoeal  infection.  Nor  is  the  fact  to  be 
overlooked  that  endocarditis,  both  in  its  benign  and  malignant  forms,  may 
be  a  secondary  process.  In  women  the  history  of  primary  gonorrhoea  is 
very  often  obscure.  Tubal  disease  and  other  pelvic  inflammations,  only 
to  be  relieved  by  the  knife  of  the  gynaecologist,  are  common  results  of  the 
extension  of  the  infection.  A  dissolute  life  on  the  part  of  the  patient  is 
presumptive  evidence  of  the  nature  of  the  process.  There  is  also  gonor- 
rhoea insontium;  a  virtuous  wife  may  suffer.  The  protean  manifestations 
of  syphilis  are  to  be  borne  in  mind.  The  symmetrical  arrangement  and 
sequence  of  the  early  cutaneous  lesions,  their  later  polymorphism  and 
irregular  distribution,  the  buccal  and  anal  mucous  patches,  the  ade- 
nopathy, the  obscurity  of  the  visceral  and  nervous  phenomena,  their 
irregularity  and  chronicity,  are  all  to  be  considered  in  the  diagnosis  of  an 
obscure  case.  The  presence  of  the  specific  organism — spirochseta  pallida — 
is  conclusive.  Where  syphilis  is  suspected  in  a  family,  we  must  inform 
ourselves  as  to  whether  or  not  a  mother  has  aborted,  especially  in  her 
early  pregnancies,  or  has  had  later  a  series  of  abortions  or  still-born  children, 
and  as  to  snuffles  and  cutaneous  eruptions,  especially  on  the  buttocks, 
in  her  new-born  children,  and  corneal  opacities,  interstitial  keratitis,  Hut- 
chinson's teeth,  and  arrested  development  or  nervous  diseases  in  those  who 
have  survived.  Nor  must  the  physician  overlook  the  fact  that  many 
innocent  persons  contract  syphilis.  Not  only  the  blameless  wife  but  also 
the  unsuspecting  girl,  from  the  kiss  of  her  betrothed,  may  become  the 
victim  to  this  disease,  while  the  methods  of  accidental  inoculation  are 
innumerable.  Familiar  examples  are  to  be  found  in  the  chancre  upon  the 
hand  of  the  surgeon  or  accoucheur,  or  upon  the  lip  or  tongue  of  the 
incautious  borrower  of  a  pipe  from  an  infected  friend.  When  matters 
of  this  kind  concern  members  of  a  family,  the  physician  cannot  be  too 
guarded  in  respect  to  the  way  in  which  his  questions  are  framed  or  in 
his  statements  to  a  husband  or  wife.  Suggestive  questioning  or  injudicious 
statements  may  seriously  aggravate  existing  troubles.  If  definite  communi- 
cations become  necessary,  his  knowledge  of  the  circumstances  will  enable 
him  to  decide  whether  it  is  best  personally  to  assume  the  whole  responsi- 
bility or  to  invite  a  colleague  of  high  reputation  to  share  it  with  him. 

The  history  of  a  surgical  operation  and  the  conditions  which  led  up 
to  it,  as  well  as  its  results,  are  important.  The  patient's  present  condition 
may  be  due  to' a  recurrence  of  the  original  trouble,  or,  as  in  the  case  of  an 
abdominal  operation,  to  the  development  of  adhesions  or  constricting  bands. 

Personal  Habits. — The  habits  must  be  closely  studied.  Important 
information  bearing  upon  the  diagnosis  may  often  be  obtained  by  direct- 
ing the  patient  while  continuing  his  ordinary  method  of  living  to  keep  a 


EXAMINATION  OF  PATIENT  AND  CASE-TAKING.  49 

record  of  the  hours  at  which  his  meals  are  taken,  the  kind  and  quantity 
of  food  and  drink,  the  action  of  his  bowels,  the  hours  and  character  of 
sleep,  and  his  various  occupations  and  amusements,  which  may  be  sub- 
mitted at  a  subsequent  consultation.  The  causal  relation  of  improper 
clothing  to  bronchopulmonary  affections,  of  badly  regulated  work  and 
sleep  to  neurasthenic  conditions,  of  injudicious  or  irregular  eating  to  gastro- 
intestinal troubles,  of  the  abuse  of  alcohol  to  nervous  diseases  and  cirrhosis 
of  the  liver,  of  excess  in  tobacco  to  irritable  heart  and  amblyopia,  will 
guide  us  in  the  inquiry.  Late  hours  and  dissipation,  in  fact  all  matters 
which  enter  into  consideration  from  the  stand-point  of  the  moral  hazard 
of  the  insurance  companies,  have  a  most  important  bearing  upon  diagnosis. 

Present  Illness. — The  history  of  the  present  illness  must  be  system- 
atically investigated  and  its  symptoms  recorded  in  chronological  order 
from  the  onset  to  the  time  of  the  patient's  coming  under  observation. 
It  is  important  to  learn  if  possible  the  effect  of  treatment.  The  disap- 
pearance of  a  rash  after  mercurials  or  the  subsidence  of  headache  after 
continued  large  doses  of  the  iodides  constitutes  presumptive  evidence  in 
favor  of  syphilis.  The  failure  of  quinine  to  prevent  the  recurrence  of  chills 
renders  the  diagnosis  of  malaria  improbable,  or  of  the  proper  administra- 
tion of  suitable  preparations  of  iron  in  full  doses  to  correct  the  pallor, 
breathlessness  upon  exertion,  and  headache  of  a  highly  anaunic  young 
woman  militates  against  the  diagnosis  of  chlorosis.  Much  allowance  must 
be  made  for  the  statements  of  patients  both  as  regards  the  symptoms  of 
the  illness  and  their  reports  of  previous  treatment  and  the  opinions  of 
physicians  whom  they  may  have^consulted.  In  many  cases  the  unravelling 
of  a  diffuse  and  inconsequent  story  can  only  be  accomplished  by  the  exer- 
cise of  skill  and  patience.  On  the  other  hand,  the  history  communicated 
by  intelligent  persons  is  often  curiously  succinct  and  clear.  Frequently 
by  reason  of  the  patient's  mental  condition  no  account  of  the  illness  can 
be  obtained.  In  some  cases  it  often  happens  that  very  little  information 
can  be  gleaned  from  the  bystanders.  In  hospital  practice  the  admission 
of  ambulance  cases  gravely  ill,  of  whose  previous  condition  nothing 
whatever  can  be  learned,  is  a  matter  of  daily  occurrence. 

Duration. — Of  first  importance  is  a  knowledge  of  the  duration  of 
the  illness,  since  it  enables  us  at  once  to  form  an  opinion  as  to  whether  the 
disease  should  be  referred  to  one  or  the  other  of  the  two  general  groups 
of  acute  or  chronic  maladies.  The  fact  is,  however,  not  to  be  overlooked 
that  acute  symptoms  may  be  the- manifestation  of  an  unsuspected  chronic 
affection,  as  sudden  loss  of  vision  or  convulsions  in  nephritis,  angina  pectoris 
in  disease  of  the  heart  and  aorta,  or  perforation  phenomena  and  peritonitis 
in  peptic  ulcer  of  the  stomach  and  duodenum.  The  mode  of  onset  next 
demands  our  attention.  In  chronic  cases  we  seek  information  as  to  whether 
the  present  illness  developed  insidiously  or  abruptly  upon  a  condition  of 
previous  good  health,  or  followed  an  acute  illness,  and  whether  its  course 
lias  been  gradual  and  progressive  or  interrupted  by  periods  of  improve- 
ment; in  acute  cases  whether  the  attack  developed  insidiously,  as  in  the 
case  of  enteric  fever,  or  abruptly,  as  in  influenza  or  typical  croupous  pneu- 
monia, and  whether  or  not  prodromes  occurred.  It  i-  nexl  in  order  to 
ascertain  the  prominent  symptoms  of  the  disease,   the  region  or  organ 

■i 


50  MEDICAL  DIAGNOSIS. 

to  which  they  have  been  referred,  whether  they  have  been  continuous, 
intermittent,  or  paroxysmal,  and  any  changes  in  the  patient's  appearance 
or  condition,  of  which  he  may  or  may  not  be  aware,  that  have  attracted 
the  attention  of  his  friends.  Finally,  important  information  is  often  reached 
by  due  consideration  of  the  views  of  the  patient  or  others  relating  to  the 
cause  of  his  illness. 

Status  Praesens. — The  investigation  of  the  present  condition  of  the 
patient  must  also  be  conducted  in  an  orderly  and  systematic  manner. 
The  subjective  sensations  are  carefully  considered.  No  complaint  of  the 
patient,  however  trifling,  is  to  be  wholly  disregarded.  The  objective 
symptoms  must  be  studied  with  equal  care.  Every  fact  is  to  receive  proper 
consideration.  Due  regard  must  be  paid  to  the  feelings  of  the  patient. 
Abruptness  and  all  appearance  of  haste  or  harshness  are  to  be  avoided. 
The  interview  must  not  seem  too  business-like.  The  clothing,  whether 
in  the  consulting  room  or  at  the  bedside,  must  be  so  arranged  as  to  facilitate 
the  examination.  No  physical  exploration  of  the  thoracic  or  abdominal 
organs  can  be  made  without  proper  access  to  the  regions  to  be  studied; 
mistakes  from  a  disregard  of  this  rule  are  of  daily  occurrence.  In  diseases 
of  the  heart,  lungs,  or  great  vessels  it  is  necessary  to  inspect  the  uncovered 
chest;  palpation  must  also  be  performed  upon  the  bare  surface;  per- 
cussion and  auscultation  upon  the  bare  skin  or  more  conveniently  in  most 
cases  through  a  towel  or  the  single  layer  of  a  smooth  under-vest.  In  order 
that  the  influence  of  gravity  upon  the  abdominal  viscera  may  be  learned 
or  to  study  the  station  and  gait,  the  patient  must  rise  from  bed.  If  there 
are  symptoms  referable  to  the  spine,  the  clothing  must  be  removed  and 
the  patient  examined  in  the  erect,  sitting,  or  recumbent  posture,  in  the  last 
instance  not  in  bed  but  upon  the  firm,  smooth  surface  of  a  suitable  table; 
the  effect  of  various  movements  is  studied  and  the  condition  of  the  muscles 
and  joints.  Accurate  measurements  of  parts,  preferably  in  centimetres, 
are  essential  where  there  is  a  departure  from  normal  standards  or  asym- 
metry. We  measure  and  note  the  circumference  of  the  head  in  hydro- 
cephalus, the  chest  on  quiet  breathing,  on  full  held  inspiration  and  on 
forced  expiration,  its  lateral  circumferences  for  comparison,  its  contour 
by  means  of  the  cyrtometer,  and  we  may  measure  diameters  of  the  head 
and  chest  by  means  of  calipers.  It  frequently,  especially  in  the  case  of 
ascites  and  tumors,  is  desirable  to  take  the  circumference  of  the  abdomen 
The  muscles  in  relaxation  and  contraction  are  studied  by  the  hand  and 
one  side  is  compared  with  the  other.  Where  necessary  the  circumference 
of  the  limbs  is  measured  at  the  same  level  upon  the  two  sides.  Where 
symptoms  relating  to  the  brain  or  spinal  cord  dominate  the  clinical  picture, 
the  examination  must  be  made  with  especial  attention  to  the  details  bear- 
ing upon  the  localization  of  the  lesions.  Specimens  of  the  urine  must  be 
obtained  for  examination  as  a  matter  of  routine  in  all  cases.  The  diagnosis 
of  obscure  conditions,  the  symptoms  of  which  are  referred  to  the  nervous 
system,  digestive  organs,  or  general  condition  of  the  patient,  frequently 
depends  upon  the  result.  The  discovery  of  chronic  disease  of  the  kidneys 
or  the  presence  of  sugar  in  the  urine  as  the  outcome  of  investigations  made 
upon  application  for  life  insurance  is  a  matter  of  very  common  occurrence 
in  middle-aged  men  who  regard  themselves  as  in  excellent  health. 


EXAMINATION  OF  PATIENT  AND  CASE-TAKING.  51 

In  general  the  examination  should  be  methodically  conducted  in  accord- 
ance with  the  foregoing  scheme,  prominence  being  given  in  the  record  of 
the  case  to  the  symptom-complex  which  bears  directly  upon  the  diagnosis. 

Abbreviations. — Time  and  space  may  be  saved  in  case-taking  by  the 
use  of  abbreviations.     Thus: 

/  &  m  I  &  w — father  and  mother  living  and  well. 

6  3;  2  d  in  infancy;   1  I  &  w — three  brothers;  two  dead  in  infancy; 

one  living  and  well. 
s  2;  1  d  at  7  sc  fever;  1  at  10  acute  nephritis, 
w  &  s  till  18  then  ent  fever;   I  crural  phlebitis;    elas  stk  still — well 

and  strong  till  IS,  then  enteric  fever;   followed  by  left  crural 

phlebitis;  still  wears  elastic  stocking. 
Epigast  pain  p  c;   occas  v;  blood  12  mos  &  1  mo  ago — Epigastric 

pain    after   food;     occasional    vomiting;     hsematamesis    one 

year  and  again  one  month  ago. 
Drua;  def  expn;    br-vesic  resp;    crep  rales — Dulness  right  side 

upper     lobe,     anteriorly;      deficient     expansion;      broncho- 
vesicular  respiration;    crepitant  rales. 
Tend  r  I  q;   circ  D;   3d  d  of  attack;  n  &  v;   T.  101°— Tenderness 

in  right  lower  quadrant;    circumscribed  dulness;    third  day 

of  attack;    nausea  and  vomiting. 

Many  similar  abbreviations,  at  once  familiar  to  the  writer  and  intel- 
ligible to  any  trained  clinician,  will  suggest  themselves. 

Murmurs  may  be  shown  on  the  clinical  diagrams  (Figs.  27  and  28) 
by  stippling  or  washes,  the  point  of  maximum  intensity  being  most 
deeply  colored  and  the  direction  of  propagation  shown  by  an  arrow; 


-m 


or  more  simply  by  a  many-pointed  star  to  indicate  the  point  of  maximum 
intensity  and  an  arrow  the  direction;  thus 


These  signs  should  be  drawn  in  a  different  color  from  that  of  t  lie 
ground  plan,  red  if  the  latter  is  black,  or  via   versa. 

Dulness  may  be  indicated  by  cross  hatching;  its  degres  by  closeness 
of  the  mesh;  thus 


Relative  dulness.  Marked  dukiese 

Flatness  by  solid  color;  thus 


52  MEDICAL  DIAGNOSIS. 

Rales  by  dots,  their  size  and  abundance  corresponding  to  the  phys- 
ical signs;  thus 


Crepitant.  Subcrepitant.  Small  mucous.  Large  mucous. 

Cavities  by  irregularly  outlined  spaces;  thus 

<SO(7 

Friction    sounds    by    zigzags,    the    extent    and    coarseness   of  which 
indicate  the  distribution  and  intensity  of  the  rub;   thus 


#  4  fywi 


The  Clinical  History. — The  result  of  the  foregoing  systematically  con- 
ducted examination  of  the  patient  is  known  as  the  clinical  history.  It  con- 
sists of  four  parts  and  is  comprised  under  the  following  corresponding  sub- 
headings : 

1.  Anamnesis. — The  account  given  by  the  patient  or  his  friends  of  the 
history  of  his  case  up  to  the  time  of  the  examination. 

2.  Status  Pilesens. — A  record  of  the  results  of  the  objective  examina- 
tion by  clinical  and  laboratory  methods. 

3.  Catamnesis  (Barker). — The  history  of  the  patient's  illness  from 
the  time  of  the  examination,  comprising  the  facts  in  the  course  of  the  disease 
and  the  details  of  treatment. 

4.  Epicrisis. — A  methodical,  critical  judgment  or  review  of  the  case 
with  the  discussion  of  questions  arising  from  its  consideration,  especially  as 
to  the  result  of  treatment  or  surgical  operation  or  the  post-mortem  findings 
in  case  of  death. 


PART   II. 

OF  THE  METHODS  AND  THEIR  IMMEDIATE   RESULTS. 


I. 


MEDICAL  THERMOMETRY. 


The  art  of  taking  and  recording  the  temperature  of  the  body  is  called 
medical  thermometry.  The  instruments  used  are  known  as  clinical 
thermometers.  They  are  marked  off  in  degrees  upon  the  glass,  and  each 
degree  is  subdivided  into  fifths,  so  that  the  readings  may  conveniently 
be  recorded  in  fractions  of  the  decimal  system.  The  thermometers  com- 
monly used  in  the  United  States  and  Great  Britain  are  marked  in  degrees 
of  Fahrenheit's  scale;  those  used  in  Europe  are  graduated  according  to  the 
Centigrade  scale.  The  scale  of  Reaumur  is  rapidly  going  out  of  use,  but  is 
still  employed  in  some  parts  of  Europe.  On  the  scale  of  Fahrenheit  the 
distance  through  which  the  mercury  rises  from  zero  to  the  boiling-point  of 
water  is  divided  into  two  hundred  and  twelve  degrees,  of  which  the  thirty- 
second  marks  the  melting-point  of  ice.  Between  the  melting-point  of  ice 
and  the  boiling-point  of  water  there  are  one  hundred  and  eighty  degrees 
(32° +  180°  =  212°  F.).  The  melting-point  of  ice  is  taken  as  zero  in  the 
Centigrade  scale  and  in  that  of  Reaumur,  but  in  the  Centigrade  the  boiling- 
point  of  water  is  at  one  hundred  (100°  C),  while  in  Reaumur's  it  is  at 
eighty  (80°  R.).    The  relation  of  the  three  scales  to  each  other  is,  therefore, — 


c. 

5 


R. 

4 


To  convert  recordings  of  the  Fahrenheit  scale  into  Centigrade  degrees, — 
Subtract  32.  multiply  by  5,  and  divide  by  9;  thus:  98.6  —  32-66.6x5 

=  333.0^-9  =  37.     That  is,  98.6°  F.  =  37°  ('. 

To  convert  Centigrade  degrees  into  Fahrenheit  degrees, — 

Multiply  by  9,  divide  by  5,  and  add  32;   thus  37x9  =  333-^5  =  66.6  + 

32  =  98.6.     That  is,  37°  C.  =  98.6°  F. 

The  Centigrade  scale  is  more  convenient   than  thai   <>f  Fahrenheit, 

and  many  physicians  in  this  country  prefer  to  use  it.     The  following  table 

of  approximate  equivalents  may  prove  of  use: 


106.7°  F.-41.5  C 
107.0°  F.-41.60  C. 
107.6°  F.  12.0°  C 
108.0  I.  42.2°  C. 
108.5°  F,  u 
109.0°  I  .  12.8  C. 
109.4°  I'.  13.0°  C 
lio.d  l.  13 
11I.'J°  F.  =  44.0   ('. 


96.0°  F.-35.5°C. 

101.3°  F 

38.5   C. 

96  8    F.     :;<,.()   C. 

102.0°  F 

=38.9   <  . 

97.8    F.     36.0°  C. 

L02.2    i 

■  39.0   1  . 

98.0°  F.-36.60  C. 

103.0    r 

39.4    C. 

98.6    1.     37.0°  C. 

103  I     1 

=  :w.:>   ( 

99.0    F.     :;7._'M\ 

104.0    1 

=  40.0    C. 

99.5    I.     37.5°  C. 

104.9    1 

M.v  C. 

100.0°  F.-37.80  ('. 

105.0    1 

-40.5°  C. 

inn.  i     |       38.0°  C. 

105.8°  F. 

=  41.0    C. 

101.0°  F.-38.3°C. 

100.0°  F. 

=  41.1°  C. 

53 


54  MEDICAL  DIAGNOSIS 

Seasoning. — As  thermometers  after  a  time  give  readings  that  are  slightly 
too  high, in  consequence  of  the  gradual  contraction  of  the  glass,it  is  necessary 
at  long  intervals  carefully  to  compare  them  with  a  standard  instrument. 
This  is  done  at  the  public  observatories,  to  which  they  may  be  sent.  This 
contraction  of  the  glass  is  called  ' '  seasoning, ' '  and  goes  on  very  slowly.  After 
two  or  three  years  it  practically  comes  to  an  end,  and  the  thermometer  is 
then  seasoned. 

Description  of  Thermometers. — Clinical  thermometers  as  at  present 
made  are  of  the  kind  known  as  maximum,  or  self-registering;  that  is,  a 
small  portion  of  the  mercury  is  separated  from  the  main  bulk  of  it,  or 
separates  itself  from  it  as  it  contracts,  by  reason  of  a  device  in  the  twist  of 
the  tube,  in  such  a  way  that  it  remains  in  position  in  the  tube  when  the 
temperature  falls,  until  shaken  down,  and  thus  indicates  the  highest  tem- 
perature reached  during  the  observation.  The  separated  portion  of  the 
mercury  is  known  as  the  "index."  The  reading  is  taken  from  the  upper 
end  of  the  index,  which  is  then  shaken  down  bv  a  quick  motion  of  the  wrist, 
such  as  is  made  in  cracking  a  whip,  the  thermometer  being  held  by  its 
upper  end.  Before  taking  the  temperature  the  index  should  be  below 
95°.  The  best  clinical  thermometers  are  now  made  with  a  curved  surface, 
which,  acting  as  a  lens,  magnifies  the  width  of  the  mercury;  and  with  a 
flattened  back,  which  lessens  the  danger  of  breakage  from  rolling.  Aseptic 
thermometers  have  an  outer  glass  tube  encasing  the  engraved  scale  so  that 
the  external  surface  is  perfectly  smooth. 

Technic. — The  object  being  to  measure  the  internal  temperature,  the 
thermometer  must  be  placed  in  such  a  position  that  the  tissues  of  the  body 
completely  surround  its  bulb.  The  positions  available  are  the  armpit,  or 
axilla,  the  mouth,  the  vagina,  and  the  rectum.  The  fold  of  the  groin,  when 
the  thigh  is  bent  up  or  flexed  over  the  abdomen,  is  in  infants  also  occasionally 
used. 

The  axilla  is  frequently  selected.  If  very  moist,  it  should  be  dried  with 
a  towel  before  the  instrument  is  introduced;  or,  if  dry  and  harsh,  it  must 
be  bathed  with  warm  water  and  then  dried.  There  is  no  difference  in  the 
temperature  of  the  two  armpits  under  ordinary  circumstances.  The  bulb 
of  the  instrument  must  be  placed  deeply  in  the  hollow  and  the  arm  brought 
well  across  the  chest.  Care  must  be  taken  that  no  fold  of  clothing  inter- 
fere with  the  contact  of  the  instrument  with  the  skin.  Some  thermometers 
are  more  sensitive  than  others;  that  is,  they  act  more  quickly.  The  mer- 
cury rises  rapidly  at  first,  then  more  slowly.  Thick  thermometers  require 
five  minutes  to  record  the  maximum  temperature,  but  the  best  instruments 
now  made  reach  the  highest  point  in  about  two  minutes.  In  the  rectum  or 
vagina  less  time  is  required. 

When  the  temperature  is  taken  in  the  mouth  the  bulb  must  be  placed 
under  the  tongue  and  the  lips  closed  about  the  stem,  the  patient  breathing 
through  his  nose.  It  is  an  excellent  plan  to  dip  the  instrument  in  water 
and  wipe  it  with  a  clean  napkin  in  the  presence  of  the  patient  both  before 
and  after  using  it  in  the  mouth.  It  is  not  safe  to  take  the  temperature  in 
the  mouth  either  in  young  children  or  in  conditions  of  delirium.  When  the 
patient  is  in  an  insensible  state,  or  when  doubts  arise  as  to  the  correctness 
of  an  axillary  observation,  the  rectum  or  the  vagina  may  be  used  for  apply- 


MEDICAL  THERMOMETRY.  55 

ing  the  thermometer,  and  with  self-registering  instruments  this  plan 
involves  no  exposure  of  the  person.  In  European  countries  the  common 
custom  is  to  take  the  temperature  in  the  rectum.  In  restless  children 
care  must  be  taken  to  prevent  the  instruments  being  broken,  and  in  all 
cases  to  prevent  a  short  thermometer  from  slipping  entirely  into  the  bowel, 
from  which  it  might  be  difficult  to  extract  it.  The  temperature  may  be 
rapidly  taken  in  unmanageable  children  by  means  of  an  old-fashioned 
thermometer  which  is  not  self-registering,  by  cautiously  warming  it  until 
the  mercury  reaches  a  very  high  point,  say  108°,  and  then  quickly  placing 
it  in  the  armpit.  The  mercury  falls  rapidly  to  the  temperature  of  the 
patient's  body  and  then  stops. 

Frequency.  —  It  is  desirable  to  take  the  temperature  at  least  twice 
daily,  the  best  times  being  between  seven  and  eight  in  the  morning  and 
about  eight  in  the  evening.  The  observations  must  be  repeated  at  the  same 
hours  each  day.  In  cases  characterized  by  great  or  sudden  variations  of 
temperature,  by  very  high  temperature,  or  when  the  influence  of  treat- 
ment upon  the  fever  is  being  closely  watched,  observations  must  be  made 
at  shorter  intervals  of  time,  and  it  may  become  necessary  to  take  the 
temperature  as  often  as  every  hour. 

Abnormal  Temperatures. 

The  temperature  in  disease  may  range  below  or  above  the  normal. 
Sudden  falls  of  temperature  in  fever  are  very  significant;  just  as  are 
abrupt  rises  from  the  temperature  of  health.  The  following  terms  are 
used  to  indicate  the  general  condition  of  the  patient  in  abnormal 
ranges   of   temperature: 

Below  the  Normal.                                                              F.  C. 

a.  Temperature  of  collapse Below       96.5°  35.8° 

b.  Subnormal  temperature 96.5°—  98°  35.8°— 36.7° 

c.  Normal  temperature 98°    —  99.5°  36.7°— 37.5° 

Above  the  Normal. 

d.  Subfebrile  temperature 99.5°— 100.5°  37.5°— 38  1° 

e.  Moderate  febrile  temperature !  100.5°— 102°     a.m.    38.1°— 38.9° 

(Mild  pyrexia) \  102.2°— 103°     p.m.  39°   —39.5° 

/.  High  febrile  temperature i  102°   —104°    a.m.  38.9°— 40° 

(Severe  pyrexia) \  104°    —105.8°  p.m.  40°    — 41° 

(j.  Intense  febrile  temperature I  ,^.  q0 i  ino  410    43  30 

I  Hyperpyrexia) J 

The  range  of  deviation  from  the  normal  within  the  limits  of  which 
life  can  be  maintained  for  brief  periods  is  comprised  between  (.>'-)0  F. 
and  110°  F.  A  temperature  of  95°  V.  on  the  one  hand  or  of  1()(>°  F. 
on  the  other,  already  indicates  great  danger,  especially  if  it  be  prolonged, 
and  beyond  these  limits  in  both  directions  the  danger  to  life  speedily 
becomes  extreme. 

(a)  Temperature  of  Collapse  or  Shock.  A  considerable  and  rapid 
fall  of  temperature  attends  the  collapse  which  sometimes  occurs  during  or 
towards  the  close  of  some  of  the  essential  fevers.  In  enteric  fever  this 
condition  may  be  produced  by  hemorrhage,  or  by  sudden  peritonitis  due 
to  perforation,  or  in  consequence  of  sudden  failure  of  the  heart.     The  list, 


56  MEDICAL  DIAGNOSIS. 

of  these  accidents  is  liable  to  occur  in  any  very  grave  case  of  fever, 
and  occasionally  follows  the  critical  fall  of  temperature  which  occurs  in 
pneumonia,  relapsing  fever,  and  more  rarely  in  other  febrile  diseases. 

Very  low  axillary  temperatures  are  met  with  in  the  stage  of  collapse 
in  the  algid  or  cold  stage  of  cholera,  the  internal  temperature  as  indicated 
by  the  vagina  or  rectum  remaining  high.  Great  depression  of  the  general 
temperature  occurs  in  the  collapse  produced  by  various  poisons,  and  espe- 
cially by  large  quantities  of  alcohol.  The  temperature  is  apt  to  fall 
considerably  below  the  normal  in  ordinary  deep  alcoholic  intoxication, 
especially  if  the  patients  have  been  exposed  to  cold  and  wet. 

(b)  Subnormal  Temperature.  —  This  condition  attends  considerable 
losses  of  blood;  starvation  from  any  cause;  the  wasting  of  certain  of  the 
chronic  diseases,  such  as  cancer  of  various  organs;  some  diseases  of  the 
brain  and  spinal  cord  and  the  later  stages  of  chronic  diseases  of  the  lungs 
and  heart,  especially  when  accompanied  by  dropsy. 

The  temperature  is  very  apt  to  reach  subnormal  ranges  in  the 
morning  for  a  few  days  at  the  termination  of  febrile  disorders. 

(c)  Normal  Temperature. — If  in  the  course  of  a  continued  fever,  as 
enteric,  the  temperature,  which  has  been  elevated  two  or  three  degrees  or 
more,  suddenly  falls  to  normal  or  near  it,  though  not  below,  this  in  itself 
is  significant  of  something  wrong,  and  may  even  acquire  the  importance 
of  the  "temperature  of  collapse,"  as  indicating  internal  hemorrhage, 
perforation,  or  failure  of  the  heart. 

(d)  Subfebrile  Temperature. — Slight  elevations  of  temperature  often 
accompany  trifling  and  transient  disturbances  of  the  general  health, 
especially  in  children.  They  are  also  observed  at  the  beginning  of 
gradually  developing  fevers,  as  enteric,  and  at  the  close  of  slowly  subsid- 
ing febrile  conditions.  In  obscure  chronic  cases  they  are  of  importance 
as  indicating  the  existence  of  actual  disease  which  may  not  manifest  its 
ordinary  symptoms. 

(e)  Moderate  Febrile  Temperature. — When  the  morning  temperature 
reaches  101°— 102°  F.  and  the  evening  shows  a  further  increase  of  one  or 
two  degrees,  we  have  to  do  with  actual  fever.  So  long,  however,  as  the 
temperature  does  not  exceed  these  limits,  there  is  no  serious  danger  from 
the  fever  process  itself. 

(f )  High  Febrile  Temperature. — When  the  temperature  in  the  morning 
is  above  102°-104°  F.  and  in  the  evening  reaches  or  ranges  higher  than 
104.5°,  the  case  becomes  serious  from  the  intensity  of  the  fever  alone, 
and  active  treatment  becomes  imperative.  High  fever  is  unattended  by 
immediate  danger  to  life  if  it  be  transient,  but  when  prolonged  it  is  ominous. 
A  temperature  of  105°  or  even  107°  in  the  hot  stage  of  an  ague,  when  the 
whole  attack  lasts  but  a  few  hours,  is  much  less  dangerous  than  the  same 
temperature  occurring,  even  for  a  short  time,  in  the  course  of  one  of  the 
continued  fevers,  when  the  patient's  powers  of  resistance  are  called  upon 
to  withstand  some  degree  of  fever  for  several  days  or  weeks. 

(g)  Hyperpyrexia,  or  Intense  Febrile  Temperature. — The  temper- 
ature reaches  105.8°  and  continues  to  rise,  or  at  all  events  does  not  fall. 
The  condition  is  one  of  extreme  and  imminent  danger  to  life.  The  resources 
of  the  art  of  medicine  are  put  to  their  severest  test.     Hyperpyrexia  often 


MEDICAL  THERMOMETRY.  57 

supervenes  with  great  suddenness.  Not  a  moment  is  to  be  lost.  The  most 
prompt  and  radical  measures  to  reduce  the  temperature  of  the  body  too 
often  fail  to  avert  the  fatal  result.  This  condition  has  been  encountered 
after  injuries  to  the  brain  and  to  the  upper  part  of  the  spinal  cord;  in  lock- 
jaw; in  sunstroke,  and  very  often  in  the  infectious  diseases,  especially 
scarlet  fever  and  pneumonia.  It  sometimes  occurs  in  rheumatic  fever, 
especially  after  the  intensity  of  the  symptoms  has  begun  to  subside,  or 
even  when  the  patient  is  apparently  almost  well.  Hyperpyrexia  is  often 
one  of  the  indications  of  approaching  death.  Hence,  in  certain  cases  the 
futility  of  treatment.  In  such  cases  a  temperature  of  110°  to  112°  is  some- 
times seen.  The  temperature  sometimes  continues  to  rise  slowly  for  an 
hour  or  two  after  death. 

The  thermometer  may  be  made  to  indicate  a  temperature  much  higher 
than  that  of  the  patient's  body,  by  friction,  or  by  being  slipped  against  a 
poultice  or  hot-water  bag,  or  into  a  cup  of  tea.  when  the  attention  of 
the  nurse  is  given  to  other  duties.  These  tricks  are  sometimes  played  by 
hysterical  girls.  They  are  readily  detected  by  repeated  observations  under 
the  eye  of  the  attendant.  A  number  of  cases  have  been  recorded  in  the 
medical  journals  in  which  excessively  high  temperatures — 120°,  150°, 
even  170°  F. — have  been  noted  and  apparently  verified  by  repeated  and 
most  careful  observations.  Many  of  the  patients  have  subsequently  been 
found  to  be  very  clever  pretenders  and  tricksters,  but  the  method  by 
which  the  high  temperatures  have  been  recorded  has  not  been  explained. 
In  such  cases  the  temperature  should  be  taken  in  several  different  regions, 
axilla,  mouth,  rectum,  etc.,  at  the  same  time,  and  the  temperature  of  the 
urine  when  voided. 

Transitory  Variations. — The  temperature  of  a  fever  patient  may  be 
somewhat  affected  by  excitement,  fatigue,  or  exposure.  Hence  hospital 
patients  often  show  for  a  few  hours  after  admission  a  temperature  higher 
than  subsequently,  or,  if  they  have  been  exposed  to  cold,  lower  than  really 
corresponds  to  their  condition. 

It  is  a  peculiarity  of  the  state  of  convalescence  from  the  acute  fevers 
that  the  temperature,  though  normal,  is  disturbed  by  trifling  causes,  and 
may  be  made  to  rise  two  or  three  degrees  by  the  first  visit  of  a  friend,  the 
first  solid  food,  or  even  by  sitting  up.  Such  rises  are  usually  very  brief, 
the  temperature  quickly  falling  again  to  normal.  They  occasion  uneasil 
iest  they  be  the  beginning  of  a  relapse.  On  the  other  hand  it  occasionally 
happens  that,  though  all  the  other  symptoms  have  disappeared  ami  the 
patient  is  almost  well,  the  temperature  remains  subfebrile,  and  the  patient 
is  for  that  reason  alone  kept  in  bed.  In  such  cases  all  traces  of  fever  vanish 
upon  cautiously  allowing  the  patient  to  sit  up  an  hour  or  so  each  day. 

Surface  Thermometry. 

This    method    is    of    inferior    value    for    diagnostic    purposes.      The 

bulb  consists  of  a  fine  coil  at  right  angles  t<>  the  tube  and  forming  an 
expanded  base  for  it.  Observations  may  be  taken  at  the  same  time 
in  corresponding  positions  on  both  sides  of  the  body.  The  general 
temperature    must    be    noted. 


58  MEDICAL  DIAGNOSIS. 

Normal  surface  temperature  (Kunkel).    Temperature  of  room  68°  F. — 20°  C. 

F.  C. 

Forehead 93.38-93.92°  34.1-34.4° 

Cheek  under  the  zygoma 93.92°  34.4° 

Tip  of  ear 83.84°  28.8° 

Back  of  hand 90.5  -91.76°  32.5-33.2° 

Hollow  of  the  hand  (closed) 94.64-95.18°  34.8-35.1° 

Hollow  of  the  hand  (open) 93.92-94.64°  34.4-34.8° 

Forearm 92.66°  33.7° 

Forearm  (higher) 93.74°  34.3° 

Sternum 93.92°  34.4° 

Pectorales 94.46°  34.7° 

Right  iliac  fossa 93.92°  34.4° 

Left  iliac  fossa 94.28°  34.6° 

Os  sacrum 93.56°  34.2° 

Eleventh  rib  (back) 94.1°  34.5° 

Tuberosity  of  ischium 89.6°  32.0° 

Upper  part  of  thigh 93.56°  34.2° 

Calf 92.48°  33.6° 

The  temperature  of  the  skin  is  slightly  higher  over  an  artery  than  at 
some  distance  from  it,  over  muscle  than  over  sinew,  over  an  organ  in  activity 
than  when  at  rest,  in  the  frontal  than  in  the  parietal  region  of  the  head, 
and  on  the  left  side  of  the  head  than  on  the  right. 

Local  elevation  above  the  general  temperature  has  been  noted  on  the 
surface  of  the  head  in  cases  of  mania  and  meningitis.  Local  elevation  of 
the  temperature  has  also  been  observed  in  cerebral  tumor  and  abscess. 
A  local  rise  of  temperature  also  occurs  over  the  painful  points  in  some 
cases  of  neuralgia  and  in  areas  of  superficial  inflammation.  The  surface 
temperature  is  increased  in  the  region  corresponding  to  the  exudate  in 
croupous  pneumonia.  Irregularly  distributed  areas  of  elevated  surface 
temperature  sometimes  occur  in  hysterical  persons. 

Subnormal  temperature  may  be  observed  in  a  limb  from  which  the 
blood  supply  is  cut  off  by  the  tourniquet  or  obstruction  of  the  main  artery, 
in  an  cedematous  or  cyanosed  part,  and  in  gangrenqus  areas.  Weir  Mitchell 
called  attention  to  the  effect  of  posture  upon  local  temperature.  He  found 
the  surface  of  the  dorsum  and  sole  of  the  foot  0.4°  C.  to  1°  C.  cooler  in  the 
erect  than  in  the  recumbent  posture. 

Charts. — The  temperature  must  be  recorded  at  once.  At  the  same 
time  a  record  of  the  pulse-beats  and  movements  of  respiration  per  minute 
is  to  be  made.  They  are  to  be  carefully  counted  while  the  thermometer 
is  in  position. 

Ruled  sheets,  called  "temperature  charts,"  or  "clinical  charts," 
are  sold  in  the  shops  for  this  purpose.  The  form  here  shown  will  be  found 
very  convenient.  It  may  be  so  kept  with  little  trouble  as  to  preserve  in  a 
compact  form  all  the  important  facts  of  an  acute  case,  and  is  equally  useful 
in  hospital  and  in  private  practice.  The  ruled  space  is  arranged  for  twenty- 
one  days  by  vertical  lines,  the  weeks  being  divided  by  heavy  lines.  The 
space  for  each  day  is  again  subdivided  for  the  morning  and  evening  record, 
as  indicated  by  the  M  and  E.  At  the  left  margin  the  purposes  of  the  spaces 
formed  by  the  transverse  rulings  are  indicated.  At  the  top  the  number 
of  movements  of  the  bowels;  immediately  below  the  quantity  of  urine 
passed,  which  may  be  recorded  in  fluidounces  or  cubic  centimetres;  then 
the  scale  of  Fahrenheit,  with  the  equivalent  Centigrade  opposite  on  the  right 


MEDICAL  THERMOMETRY. 


59 


margin.  The  coarse  horizontal  line  at  98.4°  F.  indicates  approximately 
the  normal.  At  the  bottom  are,  first,  spaces  for  each  day  of  the  disease, 
then  similar  spaces  divided  by  a  diagonal  line  for  morning  (upper,  left 
triangle)  and  for  the  evening  (lower,  right)  pulse-rate;  below  these  again 
corresponding  spaces  for  the  respiration-rate,  and  at  the  bottom  of  the 
chart  spaces  for  the  date  or  day  of  the  month. 

Important  clinical  facts,  as  "hemorrhage,"  "convulsions,"  "sup- 
pression of  urine."  etc.,  may  be  noted  at  the  time  of  their  occurrence 
between  the  vertical  lines  on  the  right  or  upper  side  of  the  chart  in  the 
position  indicated  by  the  arrows,  under  the  words  "clinical  memoranda." 


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While  changes  in  treatment,  and  in  particular  such  temporary  changes  as 
are  made  necessary  by  accidents,  like  hemorrhage,  convulsions,  or  sup- 
pression of  urine,  may  be  noted  at  the  left  or  lower  side  under  the  words 
"details  of  treatment,"  as  shown  by  the  arrows. 

The  previous  history  and  the  condition  of  the  patient  when  first  seeo 
may  be  written  on  the  back  of  the  chart. 

The  spaces  corresponding  to  a  degree  of  the  Fahrenheit  scale  are  divided 
into  fifths.  The  temperature,  as  observed,  is  designated  by  a  dot  in  the 
appropriate  position.  These  dots  joined  by  ruled  lines  form  a  zigzag  line, 
called  the  temperature  curve.  It  is  usual  to  form  the  general  curve  of  the 
case  by  means  of  the  regular  morning  and  evening  temperatures,  and  to 
indicate  the  result  of  observations  made  at  other  hours  by  dots  in  the 
appropriate  positions,  with  figures  and  letters  showing  the  hour  at  which 
they  were  made;   thus,  12  noon,  3  P.M.,  or  6  a.m. 


60  MEDICAL  DIAGNOSIS. 

It  is  customary  to  join  the  general  curve  or  range  by  lines  drawn  with 
black  ink;  the  hourly  or  three-hour  observations  by  lines  drawn  with 
red  ink.  If  the  fever  be  prolonged  beyond  three  weeks  two  or  more  charts 
may  be  pasted  together.  These  charts  thus  kept  are  not  only  of  value  for 
preservation:  they  are  also  of  immediate  use  as  showing  at  a  glance  and 
with  precision  the  facts  of  the  case  at  every  period  from  its  coming  under 
observation,  the  course  it  is  running  by  a  comparison  of  the  symptoms 
day  by  day,  and  in  a  general  way  the  effects  of  treatment,  the  changes  of 
which  are  fully  presented.  Especially  are  they  valuable  in  fevers  in  ena- 
bling us  to  watch  the  course  of  the  temperature,  which  is  a  conspicuous 
part  of  the  natural  history  of  the  disease  and  conforms  in  most  of  the  acute 
infections  to  a  type  not  only  in  its  daily  fluctuations  but  also  in  its  duration. 


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ion  refused.     Fall  <>f  temperature  following  spontaneous  rup- 
PeDnsylvania  Hospital. 


II. 

PHYSICAL  DIAGNOSIS. 

General  Considerations. — Physical  diagnosis  is  the  method  of  discrim- 
inating diseases  by.  the  direct  aid  of  the  special  senses,  namely  the  eye, 
the  ear,  the  touch.  The  diagnostic  criteria  thus  obtained  are  known  as 
physical  signs.  They  depend  upon  the  physical  nature  and  structure  of 
the  organs  or  parts  examined  and  vary  with  the  changes  caused  by  disease. 
Hence  they  are  divided  into  two  groups — normal  or  healthy,  and  abnormal 
or  morbid  physical  signs.  As  they  bear  a  direct  relation  to  the  anatomical 
condition  of  structures,  their  form,  contour,  density,  elasticity,  and  so  forth, 
and  similar  physical  conditions  may  be  present  in  different  diseases,  and  as 
morbid  processes  may  arise  in  the  absence  of  perceptible  alterations  in 
parts,  it  is  evident  that  physical  signs  taken  singly  are  not  diagnostic  of 
particular  diseases.  They  reveal  the  anatomical  condition  but  not  the 
morbid  process  causing  that  condition,  and  attain  their  full  value  in  diag- 
nosis only  when  considered  in  relation  to  other  signs  and  symptoms  and 
the  clinical  history  of  the  case. 

Pathognomonic  signs  are  those  supposed  to  be  diagnostic  of  particular 
diseases.  In  view  of  the  facts  just  mentioned,  the  use  of  the  term  pathog- 
nomonic in  this  sense  is  erroneous  in  theory  and  misleading  in  practice. 
A  physical  sign  is  the  manifestation  of  a  normal  or  morbid  physical  condi- 
tion, not  of  health  or  disease.  It  is  most  important  for  the  student  to  bear 
this  fact  clearly  in  mind.  Signs  at  one  time  regarded  as  pathognomonic, 
as  for  example  the  crepitant  rale  in  pneumonia,  are  now  known  to  occur  in 
other  conditions,  as  cedema  of  the  lungs  and  partial  atelectasis. 

Physical  diagnosis  is  constantly  employed  in  the  study  of  general  mala- 
dies and  in  local  diseases  of  all  parts  of  the  body,  but  it  is  of  special  service 
in  the  investigation  of  diseases  of  the  respiratory  and  circulatory  organs. 

Methods. — The  methods  of  physical  diagnosis  are  inspection,  palpa- 
tion, MKXSURATION,  PERCUSSION, — including  RESPIRATORY  PERCUSSION, 
PALPATORY  PERCUSSION,  and  AUSCULTATORY  PERCUSSION  and  AUSCULTA- 
tiox.  In  the  examination  of  patients  these  methods  are  used  systemati- 
cally and  in  succession,  the  signs  elicited  by  one  serving  to  confirm,  extend, 
or  control  the  knowledge  obtained  by  the  others. 

Technic. — The  physical  examination  must  under  all  circumstances  be 
conducted  in  a  routine  manner.  .More  errors  in  physical  diagnosis  arise  from 
want  of  system  than  from  want  of  knowledge.  When  the  patienl  is  in  bed, 
the  bared  chest,  abdomen, and  back  must  be  in  turn  examined  by  the  Beveral 
methods.  Under  some  circumstances  a  towel  or  a  single  thickness  of  rai- 
ment may  be  used  as  a  covering,  especially  in  percussion  and  immediate 
auscultation.      For  inspection  and   palpation  the  surface  should  be  bared. 

The  same  rules  apply  to  the  examination  of  ambulatory  patients. 
In  all  cases  the  outer  clothing  should  be  removed.  Physical  signs  cannol 
be  elicited  through  heavy  clothing,   Btarched  linen,  or  the  corset;   while 

61 


62  MEDICAL  DIAGNOSIS. 

silk,  stiff  shirt  fronts  and  the  braces  cause  upon  deep  respiratory  move- 
ments crackling  and  friction  sounds  that  have  nothing  to  do  with  the 
organs  within  the  chest.  In  all  cases  the  examination  must  be  conducted 
with  tact,  judgment,  and  due  regard  for  the  sensibilities  of  the  patient. 
The  recognition  of  abnormal  physical  signs  involves  a  familiar  knowl- 
edge of  those  which  are  normal  and  their  variations  within  the  bounds  of 
health  and  of  the  anatomy  and  physiology  of  the  organs  or  parts  examined. 
Equally  necessary  is  a  ready  knowledge  of  the  pathological  changes  upon 
which  abnormal  signs  depend.  The  skilled  diagnostician  cultivates  the 
habit  of  seeing  with  his  mind's  eye  the  changes  in  structure  caused  by 
disease.  A  long  apprenticeship  in  the  post-mortem  room  is  an  essential 
preparatory  course  for  good  work  at  the  side  of  the  bed. 

INSPECTION. 

This  method  of  physical  diagnosis  is  of  the  widest  application  in  the 
study  of  disease.  In  many  cases  a  provisional,  in  some  a  positive  diagnosis 
may  be  made  upon  a  careful  study  of  the  external  clinical  phenomena  by 
inspection  alone.  The  facies  hepatica,  emaciated  neck  and  limbs,  and 
enormously  distended  abdomen  in  cirrhosis  of  the  liver,  the  enlarged  parot- 
ids, disfigured  countenance,  and  projecting  lobule  of  the  ear  in  mumps, 
the  unilateral  flushing  and  jerky  dyspnoea  in  croupous  pneumonia,  and 
the  rash  in  the  eruptive  diseases,  tell  their  own  tale.  In  a  narrower  and 
more  technical  sense  inspection  is  especially  of  value  in  the  diagnosis 
of  diseases  of  the  thoracic  and  abdominal  organs. 

The  clothing  must  be  removed.  The  light  must  be  good.  The  skilled 
diagnostician  makes  use  now  of  direct  light,  by  which  extensive  surfaces 
are  fully  illumined;  now  of  oblique  light,  by  which  local  elevations  and 
depressions  are  accentuated  and  pulsations  are  marked  by  moving  shadows. 

By  inspection  we  otyain  information  in  regard  to  the  size,  form,  or 
contour,  the  appearance  of  the  surface,  and  the  movements  of  the  thorax 
and  abdomen. 

Inspection  of  the  Thorax. 

The  Size. — The  size  of  the  chest  is  determined  by  the  volume  of  its 
contents.  Within  the  limits  of  health  there  are  wide  variations.  A  seden- 
tary life  tends  to  shallow  breathing  and  small  lungs.  The  chest  then  con- 
forms to  the  inspiratory  type.  The  anteroposterior  diameter  is  short, 
the  upper  intercostal  spaces  wide,  the  lower  narrow,  the  costal  angle  acute. 
We  speak  of  such  a  chest  as  shallow.  Active,  out-door  occupations  favor 
habitual  deep  breathing  and  increase  in  the  size  of  the  lungs.  The  chest 
now  conforms  to  the  expiratory  type.  The  anteroposterior  diameter  is 
relatively  long,  the  upper  intercostal  spaces  narrow,  the  lower  wide;  the 
costal  angle  is  obtuse.  Such  persons  are  deep  chested.  Diseases  which 
diminish  the  size  of  the  lungs,  as  chronic  tuberculosis  and  fibroid  phthisis, 
correspondingly  reduce  the  size  of  the  thorax,  while  so-called  pseudo- 
hypertrophic emphysema  greatly  increases  its  size.  But  these  changes 
are  accompanied  by  definite  changes  in  form.  Excessive  subcutaneous 
fat  sometimes  gives  rise  to  an  apparent  increase  in  the  size  of  the  chest. 


PHYSICAL  DIAGNOSIS:     INSPECTION 


63 


The  Form. — The  form  of  the  chest  varies  with  its  size.  In  infancy 
and  early  childhood  it  is  somewhat  cylindrical, — that  is,  its  anteroposterior 
diameter  and  its  transverse  diameter  are  nearly  the  same, — and  the 
respiration  is  chiefly  diaphragmatic.  In  adults  the  cross  section  of  the 
trunk  is  oval  and  symmetrical.  Upon  deep  inspiration  the  anteroposterior 
diameter   of  the  chest  is  increased;   on  forced  expiration  it  is  diminished. 

Deformities. — The  general 
deformities  in  childhood  are  com- 
monly due  to  respiratory  obstruction 
in  the  upper  air-passages,  as  from 
adenoid  growths  in  the  nasopharynx, 
enlargement  of  the  tonsils;  or  in  the 
lungs,  as  in  bronchopneumonia  or 
phthisis.  Rickets  plays  an  impor- 
tant part.  In  adult  life  they  are 
commonly  caused  by  fibroid  changes 
in  the  lungs,  pulmonary  tuberculosis 
and  emphysema.  Unilateral  and 
local  deformities  are  caused  by  pleu- 
ral effusions,  the  retraction  which 
follows  the  resorption  or  removal  of 
such  effusions,  hypertrophy  of  the 
heart,  and  aneurismal  or  other  intra- 
thoracic tumors.  These  abnormal 
modifications  in  form  are  more 
marked  when  they  occur  early  in 
life.  The  following  deviations  in 
form  are  to  be  considered: 

(a)  The  Alar  or  Pterygoid  Chest. 
— The  chest  is  unnaturally  small  and 
narrow.  The  mesial  borders  of  the 
scapula?  project  like  budding  wings, 
the  ribs  are  extremely  oblique,  the 
shoulders  droop,  the  neck  and  chest 
appear  preternaturally  elongated, 
the  head  is  carried  unduly  forward, 
and  the  costal  angle  is  acute.  This 
form  of  chest  is  sometimes  described 
as  the  "paralytic  chest."  Persons  suffering  from  pulmonary  tuberculosis 
frequently  present  this  form  of  chest,  but  it  may  also  occur  in  poorly 
nourished   individuals   who   are   doI    phthisical. 

(b)  The  Rhachitic  Chest.  —  The  sternum  may  project,  giving  rise  to 
the  deformity  known  as  pigeon  breast.  The  sides  of  the  <  heal  are  flattened 
and  curve  forward  to  the  prominent  sternum,  as  the  sides  of  a  boat  to  the 
keel — pectus  carinatum.     Prom  the  base  of  the  ensiform  cartilage  a  broad 

shallow  depression  or  groove  passes  downward  and  outward  t<>  the  intra - 
axillary  region — Harrison's   furrow,      hi   some   instances  the   cartil 
of  the  ribs  lose  their  curve  and  become  straight,  causing  the  chest   to  be 
quite  flat  in  front  instead  of  being  rounded.     In  others  there  is  8  shallow 


]•!. 


30. 


Alar    deformity    of    chest.  —  German 
Hospital. 


64 


MEDICAL  DIAGNOSIS. 


longitudinal  groove  on  each  side  of  the  front  of  the  chest,  a  little  external 
to  the  sternum  and  nearly  parallel  to  it.  The  remarkable  deformity  known 
as  funnel  breast  sometimes  but  by  no  means  always  is  due  to  rickets. 
It  consists  in  a  deep  and  rather  abrupt  crater-like  depression  in  the  region 
of  the  base  of  the  ensiform  cartilage.  Not  rarely  there  may  be  felt  and 
sometimes  seen  a  line  of  nodular  thickenings  along  the  chondrocostal 
articulations  on  each  side,  known  by  the  fanciful  name  of  the  rhachitic  rosary. 

(c)  The  Barrel  Chest.— The 
deformity  characteristic  of  emphy- 
sema is  very  striking.  The  antero- 
posterior diameter  is  greatly 
increased.     The  thorax  is  in  a  state 


Fig.  31. — Paralytic  chest 


Fig.  32. 


-Funnel-shaped  deformity  of  chest. 
— Jefferson  Hospital. 


of  distention  greater  than  that  produced  in  health  by  the  deepest  inspira- 
tion. It  is  arched  before  and  behind.  The  manubrium  and  body  of  the 
sternum  are  sometimes  bent  at  an  angle — angulus  Ludovici.  The  shoulders 
are  high,  the  neck  short,  and  the  costal  angle  very  obtuse.  Dorsal  kyphosis 
due  to  the  carrying  of  burdens  upon  the  shoulders,  to  advancing  years,  or 
to  vertebral  caries  may  simulate  the  barrel-shaped  chest  of  emphysema, 
(d)  Deformities  of  the  Spine.  —  Curvatures  and  twisting  are  very 
common.  The  slighter  forms  are  often  overlooked.  They  may  be  recog- 
nized upon  careful  inspection  of  the  bare  back,  the  spinous  processes  being 
marked  by  a  dermatographic  pencil.  Marked  curvatures  in  which  rotary 
displacements  are  prominent  derange  the  relations  of  the  thoracic  viscera 
to  the  bony  landmarks  and  render  the  physical  examination  of  the  chest 


PHYSICAL  DIAGNOSIS:     INSPECTION. 


65 


difficult  and  the  signs  uncertain.  The  cardiac  impulse  may  be  displaced 
upward  or  to  the  left;  abnormal  bulging  may  simulate  aneurismal  or  other 
intrathoracic  tumor  and  areas  of  atelectasis  with  compensatory  emphy- 
sema occur.  Abnormal  rigidity  of  the  spine  may  be  due  to  spastic  contrac- 
tion of  the  muscles  in  Pott's  disease  or  to  spondylitis  deformans.  When 
ankylosis  has  developed  the  spine  is  persistently  rigid.  These  signs  may  be 
recognized  upon  attempts  to  bend 
forward  or  backward  or  to  rotate  the 
shoulders  while  the  pelvis  is  held 
fixed.  An  examination  of  the  verte- 
bral column  forms  part  of  every 
routine  examination  of  the  chest. 

Unilateral  changes  in  the  shape 
of  the  chest  consist  in  diminution 
and  enlargement. 

Unilateral  Diminution. — Flatten- 
ing of  one  side  of  the  chest  is  a  sign 
of  chronic  pulmonary  tuberculosis 
of  the  corresponding  lung,  fibrosis 
of  one  lung,  or  a  pleural  effusion 
which  has  undergone  resorption 
or  been  cured  by  operation.  The 
circumference  and  anteroposterior 
diameter  are  diminished;  the  bilat- 
eral diameter  is  increased;  the  .side 
is  angular  and  flattened  before  and 
behind;  the  upper  intercostal  spaces 
are  widened,  the  lower  narrowed; 
the  shoulder  is  lowered  and  there 
is  lateral  curvature  of  the  spine,  the 
convexity  being  towards  the  oppo- 
site side.  The  vicarious  enlargement 
of  the  sound  lung  gives  rise  to 
marked  differences  in  the  circum- 
ference of  the  two  sides.    When  the 

deformity  is  due  to  tuberculous  disease  of  the  upper  lobe,  the  flattening  is 
more  marked  in  the  upper  region  of  the  chest;  when  to  old  pleurisy  ii  is 
more  marked  at  the  base.  Unilateral  flattening  of  the  chesl  is  attended 
by  pleural  adhesions.  If  obstruction  of  the  main  bronchus  occurs  in  child- 
hood, the  resulting  collapse  of  the  lung  may  cause  an  acute  unilateral 
flattening  of  the  chest.  Lateral  spinal  curvature  may  simulate  diminution 
of  the  chesl  from  pulmonary  disease. 

Unilateral  Enlargement.  This  deformity  of  the  chest  is  a  sign  of 
vicarious  enlargement  of  one  lung  as  a  result  of  chronic  disease  of  its  fellow, 
pleural  effusion,  large  hemothorax,  pneumothorax,  and  rarely  of  rapidly 
growing  malignanl  disease.  Pseudohypertrophic  emphysema  may  in 
rare  instances  involve  one  lung  when  t  he  ol  her  has  undergone  fibroid  changes 
in  consequence  of  previous  disease.  The  enlarged  side  is  rounder  than  the 
other;   its  anteroposterior    diameter  longer;    the  intercostal  spaces  wide; 


Fig.  33. — Emphysematous  type  of  chesl .  —  <  Sermso 
Hospital. 


66 


MEDICAL  DIAGNOSIS. 


the  shoulder  raised  and  the  spine  curved  laterally,  the  dorsal  convexity 
being  towards  the  enlarged  side. 

The  foregoing  alterations  in  the  form  of  the  chest  are  very  obvious 
when  the  physician  stands  behind  the  seated  patient  and  looks  obliquely 
over  his  shoulders  and  the  front  of  his  chest. 

Intercostal  Spaces. — In  large  pleural  effusions  and  in  pneumothorax 
the  normal  depression  of  the  intercostal  spaces  is  obliterated  and  the 
surface  smooth  as  contrasted  with  the  opposite  side.  Bulging  of  the  inter- 
costal spaces  is  rare.  It  may  be  seen  at  the  base  of  the  chest  in  large  em- 
pyema of  long  standing. 


FlG.  .34.— Deformity  follow 


resorption  of  a  pleural  effusion. — German  Hospital. 


Local  Changes. — Local  changes  in  shape  consist  in  (a)  circumscribed 
retraction  or  (b)  prominence. 

Local  retraction  is  a  sign  of  the  following  conditions: 

Tuberculous  Consolidation  of  a  Portion  of  the  Lung. — This  is  usual  at  the 
apex  and  most  obvious  in  the  supra-  and  infraclavicular  regions.  It  is 
attended  by  pleural  adhesions. 

A  Superficial  Cavity.  —  Circumscribed  depressions  due  to  this  cause 
are  often  seen  on  the  anterior  surface  of  the  chest  near  the  sternal  border 
and  extending  over  one  or  two  intercostal  spaces.  Flattening  in  the  postero- 
lateral aspect  of  the  chest  opposite  the  spine  of  the  scapula  and  below  its 
level  is  sometimes  seen  in  pulmonary  abscess. 

Old  Pleurisy. — A  broad,  shallow  depression  in  the  anterolateral  region 
at  the  base  of  the  chest  is  common  after  pleural  effusions.  The  funnel 
breast  sometimes  follows  unilateral  pleurisy.  This  deformity  in  shoe- 
makers has  been  attributed  to  the  pressure  of  the  last  against  the  breastbone. 


PHYSICAL  DIAGNOSIS:     INSPECTION.  67 

Local  retraction  in  children  may  follow  croup,  bronchopneumonia,  and 
rickets.  The  deformities  caused  by  these  agencies  are  symmetrical  and 
have  already  been  considered. 

Local  prominence  is  a  sign  of  circumscribed  pleural  effusion,  large 
vomicae  when  distended  with  fluid,  diaphragmatic  hernia  when  congenital, 
tumor  of  the  lung  or  of  the  chest  wall,  mediastinal  tumor,  abscess  of  the 
chest  wall,  and  empyema  necessitatis.  In  a  considerable  proportion  of 
healthy  persons  that  region  of  the  chest  wall  which  overlies  the  heart  — 
the  precordial  space — is  slightly  prominent.  In  children  and  occasionally 
in  adults  prominence  of  the  precordial  space  results  from  cardiac  hyper- 
trophy or  pericardial  effusion.  The  bulging  occupies  the  space  between 
the  third  and  seventh  costal  cartilages  on  the  left  side  and  the  left  mid- 
clavicular line  and  the  sternum.  It  may  extend  to  the  right  nipple.  Aneu- 
rism of  the  arch  of  the  aorta  causes  local  bulging  of  the  chest  wall  and  in 
rare  instances  aneurism  of  the  de- 
scending aorta  may  erode  the  ribs 
and  give  rise  to  a  circumscribed 
tumor  of  the  dorsal  region  to  the 
left  of  the  spine.  Inspection  of  the 
back  frequently  reveals  local  prom- 
inences of  importance  in  diagnosis. 
A  sharp  projection  of  the  spinal 
processes  occurs  in  vertebral  caries. 
The  mesial  borders  of  the  scapulae 
stand  out  prominently  in  the  ptery- 
goid chest.  A  congenital  rounded 
tumor  in  the   middle   line,   translu- 

nonf  Qnrl  w.rtlv  rpdn  i\  1  >1p  is  thp  Fig.  35— Aueurism  of  the  descending  thoracicaorta; 
Cent     ana     paltl>     reaUClDie,     IS     me  perforation  of  chest  wall.— Penna.  Hospital. 

sign  of  spina  bifida.     This  defect  of 

development  is  frequently  associated  with  other  deformities,  ;is  hydro- 
cephalus or  club-foot.  A  dusky-red,  brawny  swelling,  commonly  in  the 
cervical  region,  discharging  pus  from  several  sinuses,  is  a  carbuncle.  It 
occurs  frequently  in  diabetes  mellitus,  and  in  all  cases  the  urine  should  be 
examined  for  sugar.  Rounded  or  lobulated  elastic  tumors,  painless  and 
usually  movable,  are  fatty.  They  sometimes  so  closely  resemble  abscesses 
as  to  require  aspiration  for  the  differential  diagnosis.  Abscesses  appear 
as  fluctuating  swellings  as  the  result  of  caries  of  the  vertebra',  usually 
tuberculous,  and  may  burrow  in  various  directions.  I  have  seen  a  large, 
oblong  tumor  to  the  left  of  the  dorsal  spine  formed  by  an  aneurism  of  the 
descending  aorta,  and  a  similar  tumor  in  the  left  lumbar  region  which  pul- 
sated and  was  connected  with  a  left-sided  empyema.  In  disseminated 
sarcoma  of  the  skin  the  lesions  are  common  on  the  back,  appearing  as 
circumscribed  nodular  masses  varying  in  size  from  a  small  shot  to  a  walnut, 
dark  in  color  and  mostly  movable. 

Surface. — The  appearance  of  the  surface  of  the  chesl  Only  excep- 
tionally yields,  upon  inspection,  physical  signs  of  importance.     We  note 

emaciation  or  an  abundant  panniculus  adiposus,  jaundice,  cyanosis  and 
pigmentation,  the  eruptions  and  scars  of  the  exanthemata  or  oi  syphilis 
or   other    chronic    disease,   enlargement    of  the   superficial    lymph-nodes  at 


68  MEDICAL  DIAGNOSIS. 

the  root  of  the  neck  and  in  the  armpits,  patches  and  lines  of  dilated 
venules  and  dilated  and  tortuous  venous  trunks.  The  appearance  of 
linear  patches  of  herpes  in  shingles — zona,  herpes  zoster — in  the  course 
of  the  intercostal  and  lumbar  nerves,  often  clears  up  the  diagnosis 
where  there  has  been  severe  burning  pain  upon  one  side  of  the  chest 
or  abdomen. 

The  Movements  of  the  Chest.  —  Normal  and  abnormal  types  of 
respiration  will  be  considered  in  a  subsequent  section.  Anomalous  move- 
ments that  affect  both  sides  of  the  chest  occur  in  dyspnoea,  inspiratory 
dyspnoea,  expiratory  dyspnoea,  Cheyne-Stokes  respiration,  exaggerated 
thoracic,  exaggerated  abdominal  breathing,  and  so  on. 

Abnormally  deep  respiration  in  the  absence  of  any  apparent  difficulty 
either  in  inspiration  or  expiration  is  seen  in  diabetic  coma. 

In  the  emphysema  of  the  aged  and  in  earlier  life  in  some  cases  of 
hereditary  syphilis  and  pulmonary  tuberculosis,  calcification  of  the  costal 
cartilages  and  associated  changes  in  the  ribs  cause  the  walls  of  the  chest  to 
move  through  a  limited  space  as  a  whole — en  cuirassc. 

Unilateral  modifications  of  the  respiratory  movements  may  consist  of 
(a)  diminished  expansion  of  one  side  or  (b)  increased  expansion  of  one  side. 

(a)  Diminished  expansion  of  one  side  may  involve  the  entire  side, 
as  in  large  pleural  effusion,  pneumothorax,  pneumonia  involving  the  whole 
of  one  lung,  tuberculous  consolidation  of  a  lung,  or  tumor  of  the  lung  or 
pleura.  The  affected  side  is  not  only  immobile  but  it  is  also  distended  and 
altered  in  contour.  In  tuberculosis  it  is,  however,  usually  contracted  in 
consequence  of  pleural  adhesions  and  sclerotic  changes  in  the  lung.  In 
massive  pneumonia  it  is  almost  immobile  but  not  enlarged.  Contraction 
also  occurs  in  the  occlusion  of  a  large  bronchus  from  the  presence  of  an 
aneurism  or  other  tumor. 

In  tuberculosis  confined  to  the  apex  of  one  or  both  lungs  there  is  failure 
of  expansion  in  the  corresponding  region  of  the  chest. 

Diminished  unilateral  expansion  may  be  a  sign  of  infradiaphragmatic 
disease — on  the  right  side,  of  an  enlarged  liver  or  hepatic  tumor;  on  the 
left,  of  an  enlarged  spleen  or  tumor  in  the  splenic  region. 

In  rare  instances  a  hemiplegia  or  paralysis  of  one  side  of  the  diaphragm 
or  a  diaphragmatic  hernia  may  be  the  cause  of  diminished  expansion  of 
one  side  of  the  chest. 

Non-expansive  inspiration  is  attended  with  retraction  of  the  inter- 
spaces. This  sign  is  especially  noticeable  in  the  inframammary,  the  infra- 
axillary,  and  the  infraclavicular  regions  in  partial  atelectasis  or  collapse  of 
the  lungs,  in  obstruction  of  the  glottis  as  in  pseudomembranous  laryngitis, 
oedema  of  the  glottis,  or  pseudomembranous  bronchitis  such  as  occurs  in 
infralaryngeal  diphtheria  or  in  the  diffuse  atelectasis  of  bronchopneumonia. 
Under  those  conditions  both  sides  are  involved.  When  a  main  bronchus 
is  occluded  the  sucking  in  of  the  intercostal  spaces  upon  inspiration  is 
limited  to  the  affected  side.  This  phenomenon  is  caused  by  intrathoracic 
negative  pressure  during  inspiration,  in  consequence  of  which  the  soft 
parts  of  the  thoracic  wall  yield  to  the  external  pressure  of  the  atmosphere. 

(b)  Increased  expansion  of  one  side  of  the  chest  is  usually  com- 
pensatory.    It  occurs  when  the  respiratory  movement  of  the  opposite  side 


PHYSICAL  DIAGNOSIS:     INSPECTION.  69 

is  interfered  with  by  pathological  conditions  of  the  lung,  as  tuberculosis, 
pneumonia,  fibrosis  and  atelectasis  from  other  causes,  or  by  pleural  effu- 
sion, pneumothorax,  or  tumor,  and  thus  becomes  a  sign  of  those  conditions. 

The  Diaphragm  Phenomenon  —  Litten's  Sign.  —  The  diaphragm  ap- 
proaches the  wall  of  the  thorax  in  expiration  and  comes  into  contact  with 
it  at  the  end  of  the  act.  It  is  separated  or  peeled  off  from  it  in  inspiration. 
These  movements  are  rendered  visible  by  the  procedure  suggested  by 
Litten  in  1892.  The  patient  is  placed  upon  his  back  with  his  chest  bared 
and  his  feet  toward  a  window.  Cross  lights  are  excluded.  If  the  examina- 
tion is  made  at  night,  a  strong  light  held  at  the  foot  of  the  bed  serves  the 
purpose.  The  observer  stands  at  a  little  distance  and  views  the  surface 
of  the  lower  part  of  the  chest  obliquely.  Upon  deep  inspiration  a  short, 
narrow,  horizontal  shadow  is  seen  to  move  from  the  sixth  intercostal  space 
downward  over  two  or  more  interspaces  upon  both  sides.  During  expira- 
tion this  shadow  moves  up  again  to  the  line  from  which  it  started  but  is 
less  distinct.  It  may  in  some  cases  be  seen  in  the  epigastrium.  This  phe- 
nomenon is  practically  present  in  all  healthy  persons,  the  only  exceptions 
being  due  to  abnormal  thickness  of  the  chest  walls  and  inability  on  the 
part  of  the  patient  to  make  full,  deep  respiratory  movements.  It  is  best 
observed  in  young,  lean,  muscular  persons.  The  extent  of  the  movement 
of  the  shadow  in  normal  chests  is  about  two  and  a  half  inches;  upon  forced 
breathing  slightly  more  than  this. 

The  descending  shadow  is  due  to  the  undulation  of  the  chest  wall 
caused  by  the  separation  of  the  diaphragm  from  its  contact  with  the  lower 
part  of  the  thorax  and  the  descent  of  the  border  of  the  lung  into  the  wedge- 
shaped  space  between  them  during  inspiration,  and  the  reverse  shadow 
by  the  retraction  of  the  lung  and  the  coming  together  of  the  diaphragm 
and  chest  wall  during  expiration. 

The  shadow  is  absent  upon  the  affected  side  in  pneumonia  of  the 
lower  lobe,  pleural  effusion,  extensive  pleural  adhesions,  intrathoracic 
tumors,  and  marked  emphysema.  In  these  conditions  the  diaphragm 
does  not  approach  and  recede  from  the  chest  wall  and  the  undulations 
which  cause  the  shadow  do  not  occur.  The  extent  of  the  movement  is 
lessened  in  conditions  of  debility,  slight  emphysema,  and  upon  the  affected 
side  in  phthisis.  In  the  latter  condition  there  are  probably  two  factors  in 
restricting  the  movement,  diminished  pulmonary  expansion  and  limited 
pleural   adhesions. 

Litten's  sign  is  present  in  hepatic  and  splenic  enlargements  and  in 
subphrenic  abscess  and  may  be  of  service  in  the  differential  diagnosis 
between  those  conditions  and  pleural  effusion.  In  very  large  ascites  it 
may  he  absent. 

The  Movements  of  the  Heart.  —  Inspection  yields  important  phys- 
ical signs  in  regard  to  the  heart  ami  great  vessels  in  health  and  disease. 
These  signs  relate  to  (a)  the  cardiac  impulse;  (b)  other  movements  of 
the  surface  having  the  cardiac  rhythm:  (1)  pulsations  at  the  root  of 
the  neck.   (2)  aneurism.    (3)   tumors  in   contact    with   large  arterial   trunks, 

(4)  pulsal  ing  empyema. 

(a)  The  Cardiac  Impulse.  -With  the  systole  of  the  heart  there  is 
seen  in  most   norma!  chests  an  outward  movement  or  pulsation  in  :i  limited 


70  MEDICAL  DIAGNOSIS. 

area  in  the  fifth  left  intercostal  space  just  beyond  the  parasternal  line — ■ 
the  visible  impulse  or  so-called  apex-beat  of  the  heart.  In  infants  and  young 
children,  owing  to  the  proportionately  greater  size  of  the  liver,  the  impulse 
is  often  visible  as  high  as  the  fourth  interspace,  while  in  aged  persons  it 
may  normally  be  as  low  as  the  sixth  interspace.  It  is  occasionally  absent 
in  healthy  persons,  especially  those  having  deep  chests  and  capacious 
lungs.  It  invariably  takes  place  at  the  time  of  the  contraction  of  the 
ventricles.  The  most  important  factor  in  the  production  of  the  impulse 
is  the  change  in  the  direction  of  the  long  axis  of  the  ventricles  against  the 
resistance  of  the  chest  wall.  It  is  a  mistake  to  speak  of  it  as  a  "blow" 
or  "impact "  against  the  wall  of  the  chest,  since  that  part  of  the  heart  which 
causes  it,  namely,  the  apex  of  the  right  ventricle,  is  already  in  contact  with 
the  wall  in  diastole  and  simply  becomes  more  tense  and  prominent  during 
systole.  Around  the  point  where  the  soft  parts  are  protruded  by  the  impulse 
they  are  very  slightly  retracted  at  the  time  of  its  occurrence — the  "negative 
impulse.'"  This  is  due  to  the  lessening  size  of  the  contracting  ventricles, 
which,  being  air-tight  within  the  cavity  of  the  chest,  must  be  followed 
down  under  the  pressure  of  the  atmosphere  by  the  elastic  and  yielding 
lungs  and  the  somewhat  yielding  intercostal  tissues.  A  clear  conception 
of  this  fact  renders  intelligible  the  systolic  recession  of  the  chest  wall 
occasionally  seen  in  emaciated  persons  in  the  third,  fourth,  or  even  the  fifth 
intercostal  space,  close  to  the  left  border  of  the  sternum. 

Since  the  normal  impulse  is  caused  by  the  apex  of  the  right  ventricle 
and  not  by  that  of  the  left,  which  extends  further  downward  and  is  sepa- 
rated from  the  wall  of  the  chest  by  a  tongue-like  projection  of  the  lower 
lobe  of  the  left  lung,  the  apex  of  the  right  ventricle  is  sometimes  spoken 
of  as  the  "clinical  apex"  and  that  of  the  left  ventricle  as  the  "anatomical 
apex"  of  the  heart. 

The  normal  impulse  is  usually  limited  in  extent,  often  not  exceeding 
an  inch  square.  Its  position  varies  somewhat  with  the  posture.  When 
the  patient  lies  upon  the  left  side,  it  may  shift  an  inch  or  more  towards 
the  axillary  line,  and  a  similar  displacement  to  the  right,  but  less  in  extent, 
takes  place  when  he  lies  upon  the  right  side.  The  impulse  is  less  marked 
and  less  extensive  in  the  recumbent  than  in  the  erect  posture.  These 
changes  in  the  position  of  the  heart  are  caused  by  corresponding  altera- 
tions in  the  position  of  the  apex  under  the  influence  of  gravity.  The  posi- 
tion of  the  impulse  is  little  influenced  by  quiet  breathing,  but  as  the  dia- 
phragm sinks  and  the  lower  ribs  are  elevated  in  inspiration  a  change  in 
the  relation  of  the  apex-beat  to  the  chest  wall,  in  some  instances  amounting 
to  an  interspace,  may  be  observed  upon  forced  breathing. 

The  impulse  becomes  forcible  and  extended  when  the  normal  heart  is 
acting  rapidly  and  with  force  under  physical  or  mental  stress  and  in  thin, 
nervous  persons,  and  it  is  often  extended  in  young  children  even  at  rest. 

The  character  of  the  impulse  and  its  extent  are  best  studied  by  palpa- 
tion, but  inspection  alone  enables  us  in  many  cases  to  determine  that  the 
impulse  is  extended,  heaving,  tapping,  or  undulatory. 

Displacements  of  the  Impulse  of  the  Heart. — Displacements  due 
to  Changes  in  the  Heart  Itself. — The  impulse  is  displaced  downward  and 
toward  the  left  in  hypertrophy  and  dilatation  of  the  heart,  and  the  combi- 


PHYSICAL    DIAGNOSIS:     INSPECTION.  71 

nation  of  these  conditions  is  the  most  common  cause.  Enlargement  of 
the  left  ventricle  tends  to  displace  the  visible  impulse  downward,  enlarge- 
ment of  the  right  ventricle  tends  to  displace  the  impulse  to  the  left,  and 
both  of  these  conditions  tend  to  increase  its  extent. 

Pressure  Displacements  are  next  in  Order  of  Frequency. — The  heart  is 
dislocated  upward  in  pressure  from  below  the  diaphragm,  as  in  excessive 
tympany,  ascites,  massive  tumors,  large  cysts,  and  pregnancy.  In  any  of 
these  conditions  the  impulse  may  be  seen  in  the  fourth  interspace  and  to 
the  left  of  the  midclavicular  line.  The  heart  in  pleural  effusion,  pneumo- 
thorax, or  rapidly  growing  malignant  tumors  of  the  pleura,  is  displaced 
towards  the  opposite  side.  When  these  conditions  are  left-sided  the 
impulse  may  disappear  behind  the  sternum  or  become  visible  at  its  right 
border,  or  in  extreme  cases  in  the  right  nipple  line.  In  large  right-sided 
effusions,  on  the  contrary,  the  impulse  may  be  displaced  as  far  left  as  the 
line  of  the  anterior  axillary  fold.  Cysts  and  abscess  in  the  right  lobe  of 
the  liver  may  displace  the  heart  somewhat  to  the  left  and  shift  the  impulse 
to  a  corresponding  extent. 

The  heart  may  be  displaced  downward  by  an  aneurism  of  the  arch  of 
the  aorta  or  a  mediastinal  tumor.  Under  those  circumstances  the  impulse 
is  not  only  lower  than  normal  but  it  is  also  somewhat  further  to  the  left. 

Traction  displacements  of  the  heart  occur  in  pulmonary  cirrhosis  and 
long-standing  disease  of  the  pleura.  The  displacement  is  toward  the  affected 
side.  Pleuropericardial  adhesions  and  negative  pressure  constitute  the 
mechanical  factors  by  which  this  group  of  displacements  is  brought  about. 
A  cardiac  impulse  may  be  seer/ to  the  right  of  the  sternum,  or  to  the  left 
of  the  left  midclavicular  line,  or  if  there  be  great  retraction  of  the  upper 
lobe  on  either  side  there  may  be  visible  cardiac  pulsation  at  the  corre- 
sponding border  of  the  manubrium.  Spinal  curvatures  and  rotations  may 
produce  such  displacement  of  the  heart  as  to  cause  a  wholly  abnormal 
position  of  the  visible  cardiac  impulse  or  its  absence  altogether.  .  Dextro- 
cardia may  be  the  cause  of  a  right-sided  impulse,  an  anomaly  also  present 
in  complete  transposition  of  the  viscera. 

Systolic  Retraction.  —  I  have  already  spoken  of  the  negative 
impulse  present  under  normal  conditions  in  the  immediate  proximity  of 
the  apex-beat  and  the  more  extended  systolic  recession  of  the  interspaces 
occasionally  seen  along  the  lower  sternal  border.  These  are  distinctly 
accentuated  when  a  hypertrophied  and  somewhat  dilated  heart  is  acting 
forcibly.  As  these  forms  of  systolic  recession  are  due  to  atmospheric  pres- 
sure, they  may  be  spoken  of  as  pulsion  recessions  in  contradistinction  to 
those  due  to  the  drawing  in  of  the  surface  in  consequence  of  adhesions, 
which  may  be  called  traction  recessions. 

The  latter  are  seen  in  adherent  pericardium  with  chronic  niediastinit is. 
The  impulse  is  undulatory  and  in  t  he  region  of  t  he  apex  t  here  is  marked  sys- 
tolic retraction.  Owing  to  the  enlargement  of  the  heart  t  he  precordial  region 
is  prominent  and  the  chest  asymmetrical.    The  impulse  is  greatly  extended. 

Broadbent's  Sign.-  When  the  heart  is  extensively  adherent  to  the 

diaphragm,  there  occurs  with  each   pulsation  a  systolic  tug.     This  may  be 

communicated  through  the  diaphragm  to  the  points  of  its  insertion  in  the 
wall  of  the  chesl  and  well  seen  in  the  eighth  and  ninth  intercostal  spaces  in 


72  MEDICAL  DIAGNOSIS. 

the  parasternal  line;  but  Broadbent  has  pointed  out  the  fact  that  it 
is  often  also  seen  on  the  left  side  behind,  between  the  eleventh  and 
twelfth  ribs.  Careful  inspection  in  this  region  will  frequently  reveal  a 
systolic  retraction  of  the  chest  wall,  which  becomes  more  evident  upon 
deep  inspiration. 

Visible  Pulsations  of  the  Heart  in  Regions  other  than  the 
Apex. — These  are  mostly  due  to  retraction  of  the  lungs.  In  debilitated 
and  bed-ridden  persons  and  especially  in  the  graver  forms  of  anaemia,  the 
breathing  is  shallow  and  the  lungs  are  not  fully  expanded.  Their  borders 
are  therefore  more  or  less  withdrawn  from  the  space  which  they  normally 
occupy  between  the  heart  and  the  chest  wall.  The  pulsations  of  the  conus 
arteriosus  and  right  ventricle  thus  frequently  become  visible  in  the  second, 
third,  and  fourth  left  interspaces  near  the  sternal  border.  In  some  instances 
these  pulsations  may  also  be  observed  to  the  right  of  the  sternum.  Such 
pulsations  are  also  seen  when  the  borders  of  the  lungs  are  retracted  as  the 
result  of  fibroid  phthisis. 

(b)  Other  Movements  of  the  Surface  of  the  Chest  having  the  Cardiac 
Rhythm. 

1.  Pulsations  at  the  root  of  the  neck  will  be  described  and 
their  significance  as  physical  signs  pointed  out  in  a  subsequent  section. 
They  are  venous  and  arterial. 

Prominence  of  the  veins  of  the  neck  is  observed  in  emaciated  and 
elderly  persons  otherwise  in  health.  These  veins  are  more  or  less  distended 
upon  expiration,  particularly  when  cough  occurs  or  dyspnoea  is  present. 
Transient  engorgement  results  from  efforts  at  lifting  or  from  straining. 
Pathological  conditions  that  give  rise  to  engorgement  of  the  jugulars  are 
aneurism,  mediastinal  tumor,  adhesive  mediastinitis,  and  obstruction  to 
the  pulmonary  circulation  from  any  cause.  Respiratory  engorgement 
and  collapse  of  the  jugulars  are  especially  marked  in  the  dyspncea  of 
asthma  and  emphysema.  ' 

Collapse  of  the  jugular  upon  one  side,  not  disappearing  when  pressure 
is  made  upon  it  immediately  above  the  clavicle,  is  a  sign  of  thrombosis  of 
the  lateral  sinus. 

Pulsating  Jugulars.  —  The  pulsations  are  best  studied  on  the  right 
side  of  the  neck  and  during  quiet  breathing.  Pulsation  communicated 
from  the  underlying  carotid  may  be  recognized  by  emptying  the  vein  by 
stripping  it  upward  gently  with  the  finger-nail  or  the  blunt  edge  of  the 
tongue  spatula.     It  does  not  refill  from  below. 

The  visible  pulsations  in  the  carotids  often  seen  in  thin,  nervous  persons 
without  disease  of  the  heart  are  without  clinical  importance.  Violent- 
throbbing  of  the  carotids  is  common  in  aortic  regurgitation  and  frequently 
occurs  in  simple  hypertrophy  of  the  heart  without  valvular  lesions. 

2.  Aneurism. — Careful  inspection  of  the  anterior  surface  of  the  chest 
must  be  made  in  all  cases  of  suspected  aneurism.  Direct  and  oblique 
illumination  must  be  in  turn  employed,  and  the  examination  must  be  so 
conducted  that  profile  views  are  made  from  above,  the  patient  being  in 
the  sitting  posture,  and  from  the  side,  the  patient  being  recumbent.  In 
this  way  slight  pulsations  and  pulsating  prominences  may  be  discovered. 
The  pulsation  of  aortic  aneurism  is  commonly  present  in  the  first  and  second 


PHYSICAL  DIAGNOSIS:     INSPECTION. 


73 


right  interspaces  near  the  sternal  border  and  is  sometimes  accompanied 
by  slight  systolic  elevation  of  the  inner  end  of  the  clavicle.  When  the 
innominate  is  involved  the  pulsation  may  be  seen  at  the  root  of  the  neck 
upon  the  right  side  or  at  the  notch  of  the  sternum.  Aneurismal  pulsations 
sometimes  occur  to  the  left  of  the  manubrium  sterni  and  elsewhere  in  the 
chest  and  are  to  be  sought  for  in  every  doubtful  case.  Aneurisms  that 
have  perforated  the  chest  wall  appear  as  circumscribed  globular  or  irregular 
pulsating  tumors,  the  overlying  skin  being  thinned  and  adherent  and 
ultimately  ulcerated,  so  that  there  is 
superficial  clot  formation  and  more 
or  less  continuous  oozing  of  blood. 
The  tumor  may  be  soft  and  fluctu- 
ating; more  commonly  in  conse- 
quence of  the  deposition  of  stratified 
fibrin  layers  within  the  sac  it  is  dense 
and  resistant.  In  the  former  case 
the  pulsation  is  expansile;  while  in 
the  latter  case  it  is  apt  to  be  non- 
expansile,  but  forcible  and  heaving. 

3.  Tumors  in  Contact  with 
Large  Arterial  Trunks. —  En- 
larged lymph-nodes,  especially 
when  single,  and  neoplasms  in  the 
neck  overlying  the  carotid  artery 
sometimes  move  synchronously 
with  the  pulsations  of  the  vessel  and 
present  superficial  resemblances  to 
aneurisms.  The  tumor  is  dense, 
the  pulsation  not  expansile,  and 
other  signs  of  aneurism  are  lacking. 

4.  Pulsating  Pleurisy. — In 
neglected  purulent  effusions  a  pul- 
sating movement  synchronous  with 
the  cardiac  rhythm  is  sometimes 
observed.  The  cases  are  not  numer- 
ous. The  phenomenon  is  almost 
always  associated  with  left-sided 
effusions  and  occupies  an  extensive 
area  of  the  lower  anterolateral  sur- 
face of  the  left  chest.  In  cases  where  it  is  circumscribed  and  confined 
to  the  precordial  region  the  differential  diagnosis  relates  to  aneurism 
and  is  attended  with  difficulty.  A  limited  number  of  cases  have  been 
right-sided  and  in  <»ne  or  two  of  the  reported  instances  the  effusion  has 
been  serofibrinous.  Pulsating  empyemata  may  be  intrapleural  or  the 
pulsations  may  occur  in  the  extrapleural  empyema  necessitatis.  None  of 
the  explanations  of  the  mechanism  by  which  the  cardiac  impulse  in  these 
cases  is  transmitted  through  the  pus  collection  to  the  surface  of  the  chest 
is  satisfactory.  An  important  factor  is  superficial  ulceration  of  the  costal 
pleura  with  loss  of  tone  in  the  intercostal  muscles. 


Fio.  36. — Aneurism  of  the  thoracic  a 
I  [ospital. 


74  MEDICAL  DIAGNOSIS. 

Inspection  of  the  Abdomen. 

In  the  examination  of  this  portion  of  the  body  the  patient  should  be 
in  the  recumbent  position  and  preferably  in  bed.  The  abdomen  in  exposeoj 
from  the  arch  of  the  ribs  to  the  suprapubic  region.  The  patient  should 
lie  straight  and  flat.  The  head  should  be  at  first  low  and  the  lower  limbs 
extended;  later  the  head  should  be  raised  upon  pillows  and  the  thighs  and 
knees  strongly  flexed,  the  heels  being  drawn  up  towards  the  buttocks, 
in  order  to  relax  the  abdominal  wall ;  finally  it  is  often  necessary  to  have 
the  patient  assume  the  standing  posture,  in  which  case  the  clothing  or  a 
sheet  is  supported  about  the  hips  by  the  patient  or  an  assistant.  The  light 
must  be  good  and  the  examination  made  from  above,  from  the  sides  and 
obliquely.  Physical  signs  of  importance,  such  as  asymmetry  in  contour 
or  movement  or  slight  local  elevation  or  depression  of  the  surface,  may 
often  be  detected  when  otherwise  not  very  obvious,  if  the  observer  stands 
at  the  patient's  head  and  views  the  abdomen  obliquely  from  above  down- 
wards. Combined  inspection,  palpation,  and  percussion  are  necessary. 
Auscultation  is  of  inferior  value  in  the  examination  of  this  region. 

(a)  The  Normal  Abdomen.  —  In  infants  and  young  children  the 
abdomen  is  relatively  larger  as  compared  with  the  size  of  the  chest  than  in 
adults.  It  is  also  more  protuberant  than  in  well-formed  adults.  It  is 
larger  in  women  than  in  men  and  is  enlarged  and  protuberant  in  obese 
and  elderly  persons.  In  thin  women  who  have  borne  many  children  it  is 
relaxed,  coarsely  wrinkled,  and  pendulous.  Tight  corsets  cause  bulging 
of  its  lower  segment.  Transient  prominence  of  the  upper  segment  may 
sometimes  be  observed  after  a  hearty  meal. 

'  The  size  of  the  abdomen  in  health  varies  greatly  in  different  individuals 
according  to  the  amount  of  subcutaneous  and  omental  fat  and  the  size  of 
the  intestines,  which  are  apt  to  be  distended  in  persons  who  habitually 
eat  large  quantities  of  coarse  food.  The  physiological  enlargement  of  the 
abdomen  in  pregnancy  is  frequently  enormous. 

The  normal  abdomen  is  symmetrical  in  contour,  slightly  arched  from 
above  downward  and  from  side  to  side,  the  curves  being  more  prominent, 
especially  in  the  lower  part,  in  the  erect  than  in  the  recumbent  posture. 
The  navel  is  shallow  and  marked  by  irregularly  spiral  folds  of  skin  in  thin 
persons  and  deep  and  funnel-shaped  in  those  who  are  fat. 

The  skin  of  the  abdomen  in  healthy  persons  is  opaque  and  the  super- 
ficial veins  are  not  conspicuous.  In  brunettes  regularly  distributed  areas 
of  increased  normal  pigmentation  are  present  in  the  median  line  and 
above  the  flexures  of  the  thighs.  This  coloration  is  deepened  and  con- 
spicuous in  pregnancy — chloasma  uterinum.  The  respiratory  movements 
of  the  diaphragm  are  communicated  to  the  upper  portion  of  the  abdomen, 
the  ensiform  cartilage  and  the  arch  of  the  ribs  being  elevated  and  becom- 
ing more  prominent  with  inspiration.  In  persons  with  very  thin  and 
relaxed  abdominal  walls  the  peristaltic  movements  of  the  stomach  and 
intestines  may  be  occasionally  seen. 

(b)  Inspection  of  the  Abdomen  in  Disease.  —  We  study  the  size  of 
the  belly  as  manifest  in  general  or  local  retraction  or  distention,  alteration 
in  form  and  contour,  the  appearance  of  the  surface  and  abnormal  move- 


PHYSICAL  DIAGNOSIS:     INSPECTION.  75 

merits.  In  this  connection  the  general  rule  that  the  size  of  a  hollow  ana- 
tomical structure  or  viscus  varies  with  the  contents  must  be  borne  in  mind. 

General  Retraction  of  the  Abdomen.  —  When  the  longitudinal  and 
transverse  curves  of  the  surface  are  reversed  and  become  concave  instead 
of  convex,  the  abdomen  is  described  as  scaphoid  or  boat-shaped.  Two 
factors  may  cause  this  condition  and  they  are  frequently  combined,  namely, 
extreme  wasting  and  irritative  tonic  spasm  of  the  abdominal  walls.  The 
former  occurs  in  actual  starvation;  inanition  from  any  cause,  especially 
malignant  disease  of  the  larynx  or  oesophagus,  stricture  of  the  latter  from 
other  causes,  stricture  of  the  pylorus  without  marked  gastric  dilatation, 
diabetes,  phthisis,  cerebrospinal  fever,  cholera,  chronic  diarrhoea,  anorexia 
nervosa, and  the  pernicious  vomiting  of  pregnancy;  the  latter,  in  meningitis, 
cerebral  tumor,  and  lead  colic,  and.  especially  when  combined  with  muscular 
rigidity  and  marked  tenderness,  is  a  most  important  sign  of  early  peritonitis. 

Extreme  retraction  of  the  abdomen  occurs  in  wasting  of  the  subcu- 
taneous and  omental  fat  and  atrophy  of  the  abdominal  organs. 


Fig.  37. — Scaphoid  abdomen  caused  by  starvation  in  a  case  of  oesophageal  carcinoma. — Jefferson  Hospital. 

Local  retractions  of  the  abdomen  are  not  of  importance  as  physical 
signs.  They  are  seen  around  the  base  of  large  hernias,  especially  in  the 
lateral  regions  of  the  abdomen,  in  large  ventral  hernias,  and  in  the  upper 
regions  in  diaphragmatic  hernias.  These  areas  of  depression  disappear 
when  the  hernias  which  cause  them  are  reduced. 

In  moderately  large  peritoneal  effusions  of  some  standing,  when  the 
patient  assumes  the  lateral  decubitus  the  side  of  the  abdomen  which  is 
uppermost  shows  a  concave  retraction  while  the  anterior  and  dependent 
portions  bulge  more  prominently. 

General  Distention  of  the  Abdomen. — This  condition  may  be  caused 
by  subcutaneous  and  intra-abdominal  fat,  the  excessive  accumulation  of 
gas  in  the  stomach  or  intestines,  fluid  in  the  abdominal  wall  or  peritoneal 
cavity  or  both  combined,  or  a  large  intra-abdominal  tumor  or  cyst. 

Subcutaneous  and  intra-abdominal  fat  accumulations  in  the  obese 
frequently  cause  enormous  distention  of  the  belly.  In  such  cases  there  is 
excessive  and  often  irregular  development  of  the  panniculus  adiposus  else- 
where; while  in  ascites  and  tumor  t  he  general  nut  lit  ton  is  usually  impaired. 
In  cases  where  there  is  reason  to  suspect  pregnancy  or  the  presence  of  an 
abdominal  tumor  a  large  deposit  of  fat  may  render  the  diagnosis  diffi- 
cult. Large  accumulations  of  fat  in  the  omentum,  such  as  sometimes 
occur  in  persons  of  middle  age,  may  simulate  pregnancy  or  a  tumor. 
Fat  in  the  belly  walls  interferes  greatly  with  the  examination  by  means 
of   the    X-rays. 


76  MEDICAL  DIAGNOSIS. 

The  Excessive  Accumulation  of  Gas  —  Meteorism,  Tympanites. — The 
distention  is  symmetrical  and  may  be  extreme.  There  is  tympanitic 
percussion  resonance  and  absence  of  fluctuation.  The  association  of  these 
physical  signs  renders  the  diagnosis  easy.  When  extreme  the  condition 
causes  restriction  of  respiratory  movement,  the  disappearance  of  the 
respiratory  excursus  in  the  epigastric  zone,  and  displacement  of  the 
cardiac  impulse  upward  as  high  as  the  fourth  interspace  and  to  the 
left  of  its  normal  position. 

Moderate  distention  may  result  from  injudicious  eating,  acute  and 
chronic  gastro-intestinal  disorders,  especially  in  neurotic  persons,  and  the 
slight  paresis  of  the  intestines  which  occurs  in  acute  febrile  diseases,  as 
enteric  fever  or  pneumonia.  Nervous  women  are  apt  to  "bloat."  as  it 
is  popularly  called,  after  eating.  Excessive  tympany  occurs  in  grave 
cases  of  the  infectious  diseases,  as  enteric  fever  with  deep  ulceration, 
septic  conditions,  acute  general  peritonitis,  intestinal  obstruction,  after 
the  release  of  a  constricted  loop  of  intestine  after  operation,  as  in 
strangulated   hernia,  and   in   some   cases  of  hysteria. 


Fig.  38. — Ascites,  caused  by  cirrhosis  of  the  liver. — Jefferson  Hospital. 

Free  gas  in  the  peritoneal  cavity  occurs  as  the  result  of  the  perforation 
of  an  air-containing  viscus-  into  that  space.  The  abdomen  is  greatly  and 
uniformly  distended,  its  surface  tense  and  smooth,  the  outlines  of  intestinal 
convolutions  and  vermicular  movements  are  not  visible,  and  the  respira- 
tory movement  of  the  upper  part  of  the  abdomen  ceases.  The  most  common 
causal  conditions  are  peptic  ulcer  of  the  stomach  or  duodenum,  a  perforat- 
ing typhoid  ulcer,  and  ulcerative  or  necrotic  appendicitis.  As  the  air  occu- 
pies the  highest  region  of  the  cavity,  it  causes  a  disappearance  of  the  normal 
percussion  dulness  of  the  liver  and  spleen,  which  is  replaced  by  a  tympanitic 
note  in  these  areas,  of  the  same  character  as  that  over  the  abdomen  else- 
where. The  mere  disappearance  of  the  hepatic  dulness  does  not,  however, 
justify  the  diagnosis  of  pneumoperitoneum,  since  the  intestines  and  espe- 
cially the  transverse  colon  may  occupy  the  space  between  the  liver  and 
the  wall  of  the  thorax  and  separate  them  completely.  Moreover,  the  liver 
dulness  may  be  greatly  diminished  in  pulmonary  emphysema  of  high  grade, 
atrophic  cirrhosis  of  the  liver  and  acute  yellow  atrophy.  The  diagnosis  of 
free  air  in  the  peritoneum  may,  however,  be  determined  by  careful  per- 
cussion in  the  axillary  line  according  to  the  following  procedure:  In  the 
dorsal  posture  there  is  dulness  alike  in  the  condition  under  consideration 
and  when  the  liver  is  separated  from  the  wall  of  the  thorax  anteriorly  by 
the  distended  intestine.     When,  however,  the  patient  is  turned  upon  his 


PHYSICAL  DIAGNOSIS:     INSPECTION. 


77 


left  side  there  always  remains  a  limited  area  of  dulness  in  the  axillary 
line  high  up  in  the  case  of  meteorism,  while  the  dulness  wholly  disap- 
pears in  the  case  of  pneumoperitoneum.  The  same  method  of  exam- 
ination is  applicable  to  the  spleen,  although  the  small  size  of  this  organ 
renders  its  recognition  alike  in  large 
meteorism  and  in  pneumoperitoneum  a 
matter  of  much  greater  difficulty  than 
in  the  case  of  the  liver. 

Fluid  in  the  Abdominal  Wall  or 
Peritoneal  Cavity. — An  excessive  dropsy 
of  the  wall  in  some  cases  of  anasarca 
may  cause  distention  of  the  abdomen. 
This  condition  is  encountered  in  acute 
nephritis  and  in  the  later  stages  of 
cardiovascular  disease.  The  abdomen  is 
tense,  doughy,  and  pits  upon  pressure; 
the  more  dependent  parts  of  the  body, 
feet,  ankles,  legs,  thighs,  and  pudenda,  are 
highly  oedematous,  and  the  condition  is 
usually  associated  with  effusion  into  the 
peritoneum  and  sometimes  also  into  the 
other  serous  cavities.  The  pallid  and  puffy 
facies  in  acute  nephritis  is  characteristic. 

Ascites  or  free  fluid  in  the  cavity  of  the 
'peritoneum  yields  characteristic  physical 
signs.  The  enlargement  of  the  abdomen 
is  general  and  symmetrical.  Its  degree 
and  outline  depend  upon  the  amount  of 
the  fluid  and  the  fact  that  under  the 
influence  of  gravity  it  changes  its  position  with  changes  in  the  posture 
of  the  patient.  In  moderate  effusions,  in  the  dorsal  decubitus  the  middle 
of  the  abdomen  is  more  or  less  flattened  while  the  lateral  regions  bulge 
outward,  in  the  lateral  decubitus  the  lower  lateral  and  anterior  walls  of  the 


OB 

Fig.  39. — Ascites.— German  Hospital. 


Fig.  40. — Pregnancy — ninth  nulnth. 


belly  protrude  while  that  which  is  uppermost   is  slightly  incurved,   in  the 
knee-elbow  posture  the  weight  of  the  fluid  causes  the  abdomen  to 
down  in  an  unusual  manner,  and  in  the  erect  posture  the  lower  segmenl  oi 
the  abdomen  is  especially  prominent.     In  all  these  positions  there  is  dul- 
ness upon  percussion  over  the  dependent  areas  and  tympanitic  resonance 


78 


MEDICAL  DIAGNOSIS. 


over  the  upper,  since  the  fluid  gravitates  toward  the  dependent  regions  of 
the  cavity  and  the  air-containing  intestines  float  upon  it  in  the  upper 
spaces.  Ascites  in  a  belly  previously  relaxed  or  pendulous  causes  in  the 
erect  posture  a  prominent  and  somewhat  conical  symmetrical  protrusion 
of  the  lower  parts.     Massive   ascites   gives  rise  to  uniform  symmetrical 

enlargement  of  the  abdomen,   but  little  influ- 
enced by  change  of   posture. 

Ascites  results  from  pathological  processes 
directly  implicating  the  peritoneum,  as  ordinary 
infections  or  tuberculous  inflammation  or  can- 
cer, or  the  portal  vessels,  as  the  pressure  of  new 
growths,  gall-stones,  cancerous  invasion,  extreme 
sclerosis  or  pylephlebitis  due  to  other  causes,  or 
disease  of  the  liver.  Cirrhosis  of  the  liver  is  a 
common  cause  of  ascites.  Tumors  of  the  abdo- 
men and  especially  large  solid  tumors  of  the 
ovary  are  frequently  attended  by  ascites.  The 
foregoing  have  been  spoken  of  as  local  causes. 
The  general  causes  of  ascites  are  those  which 
give  rise  to  anasarca  and  effusion  into  the  other 
serous  sacs.  Peritoneal  effusion  resulting  from 
local  causes  is  not  usually  at  first  associated 
with  oedema  of  the  lower  extremities.  As  the 
fluid  accumulates  it  exerts  pressure  upon  the 
large  abdominal  veins,  especially  the  iliacs  and 
ascending  vena  cava,  giving  rise  to  dropsy. 

Tumor  as  a  Cause  of  General  Abdominal 
Enlargement. — The  pregnant  uterus,  ovarian, 
pancreatic,  and  hydatid  cysts,  and  large  new 
growths  cause  distention  which  may  simulate 
that  due  to  the  causes  just  considered.  The 
enlargement  caused  by  these  conditions  differs 
from  that  caused  by  fat,  tympany,  or  fluid  in 
being  usually  more  prominent  in  the  anteropos- 
terior than  in  the  bilateral  diameter,  not  so  sym- 
metrical, and  not  yielding  uniform  signs  upon 
palpation  and  percussion.  Other  causes  of  gen- 
eral enlargement  of  the  abdomen  are  fecal  accu- 
mulation, cancer  of  the  bowel,  disseminated  cancer  of  the  peritoneum,  and 
large  peritoneal  or  retroperitoneal  sarcomata  and  lipomata.  To  this  list  must 
be  added  hydronephrosis  and  enormous  dilatation  of  the  stomach  or  colon. 
Local  Prominence  of  the  Abdomen. — Circumscribed  swellings  or  tume- 
faction may  be  caused  by  abnormal  conditions  of  the  belly  wall  or  of 
the  contents  of  the  cavity.  These  changes  in  contour  should  be  carefully 
sought  for  in  all  cases  presenting  symptoms  referable  to  the  abdominal 
viscera.  The  methods  of  especial  value  are  inspection,  palpation,  and  per- 
cussion.    In  thin  persons  radioscopy  yields  important  results. 

The  recognition  of  the  nature  of  local  bulgings  in  the  abdominal  wall 
is  as  a  rule  not  attended  by  great  difficulty,  but  the  diagnosis  of  visceral 


Fin.  41. — Dilatation  of  colon 
Male,  12  years  old. — Rotch. 


PHYSICAL   DIAGNOSIS:     INSPECTION. 


79 


tumors  is  frequently  obscure  and  in  many  cases  can  only  be  positively 
determined  by  an  exploratory  operation. 

Local  Prominences  due  to  Changes  in  the  Wall  of  the  Ab- 
domen.— These  comprise  abnormal  conditions  of  the  muscles,  irregular 
collections  of  subcutaneous  fat,  hernia,  abscess,  enlarged  lymph-glands, 
and  neoplasms,  particularly  sarcomata. 

.4.  spasmodically  contracted  rectus  muscle  may  simulate  a  tumor.  The 
diagnostician  must  be  on  his  guard  against  the  appearance  and  sensation 
imparted  to  the  touch  by  a  contracted  right  rectus  in  the  pyloric  region. 

Phantom  Tumor. — The  condition  known  as  phantom  tumor,  due  to 
persistent  gaseous  distention  of  a  knuckle  of  gut  with  spasmodic  contrac- 
tion of  the  overlying  muscle,  causes  a  tumor-like  swelling.    Such  swellings 


Fin.  42. — a,  epigastric  hernia;  6,  hernia  reduced. 

appear  and  disappear,  with  alterations  in  contour  and  position;  sometimes 
subside  under  gentle  friction  with  the  warmed  hand  and  always  under 
anaesthesia.  They  occur  in  hysterical  persons.  Fitz  has  suggested  that 
in  some  of  the  cases  phantom  tumors  are  symptomatic  of  congenital  or 
acquired  dilatation  of  the  colon. 

Fat. — In  very  obese  persons  remarkable  rolls  and  masses  of  sub- 
cutaneous fat  collect  in  the  abdominal  wall.  These  are  usually  luit  not 
always  symmetrical  in  arrangement,  and  may  simulate  tumors,  from  which 
they  may  be  differentiated  by  their  continuity  with  the  panniculus  adi- 
posus.  their  consistency  and  want  of  tenderness, and  the  general  condition 
of  the  patient.  Circumscribed  fatty  tumors — lipomata  are  common. 
They  are  hemispherical  or  egg-shaped,  elastic,  painless,  somewhat  mov- 
able, and  more  common  in  the  lateral  and  posterior  aspects  of  the  trunk 
than  in  the  abdominal  wall.     They  frequently  occur  in  spare  persons. 

Hernia.  No  examination  of  the  abdomen  is  complete  that  does  not 
include  the  sites  of  hernia.     This  is  especially  important   in  cases  attended 


80  MEDICAL  DIAGNOSIS. 

by  intestinal  obstruction  and  vomiting,  or  persistent  pain  in  the  inguinal 
region.  The  inguinal  and  femoral  regions  should  be  examined  by  palpation 
under  the  cover  of  the  sheet  or  clothing  and  if  necessary  by  inspection  as 
well.  Ventral  and  umbilical  hernias  and  scar-hernias  after  operation  may 
be  readily  recognized.  The  tumor  varies  in  consistency  according  as  it 
consists  wholly  of  gut  or  partly  of  omentum.  It  is  usually  soft,  without 
pain  upon  manipulation,  and  reducible.  It  varies  in  size  from  a  mere  nodule 
to  a  sac  containing  a  large  portion  of  the  abdominal  contents.  It  very 
often  disappears  spontaneously  when  the  patient  assumes  the  recumbent 
posture,  or  is  then  readily  reduced.  Strangulated  hernia  does  not,  as  a  rule, 
yield  to  taxis. 

Abscess. — Purulent  collections  in  the  abdominal  wall  may  be  recog- 
nized by  the  signs  of  inflammation,  swelling,  redness,  heat,  and  pain,  by 
their  contour,  and  especially  by  fluctuation.  Pus  may  form  in  any  part 
of  the  wall  or  find  its  way  to  any  point  upon  the  surface.  Appendiceal 
abscess  usually  forms  a  circumscribed,  fluctuating  tumor  in  the  right 
lower  quadrant  of  the  abdomen. 

Lymph-nodes. — The  superficial  lymphatic  glands  of  the  groin  do  not 
form  visible  tumors  unless  distinctly  enlarged.  They  are  frequently  pal- 
pable as  small  nodular  bodies  in  adults  who  are  in  good  health.  They  may 
become  enlarged  and  tender  in  injuries  of  the  leg  or  foot,  in  venereal  disease, 
and  in  common  with  the  superficial  lymph  nodules  in  other  parts  of  the 
body  in  some  of  the  acute  infectious  diseases  and  in  particular  in  the  bubonic 
plague.  Slight  enlargement  of  the  inguinal  lymphatics  is  common  in  gener- 
alized malignant  diseases — carcinomatosis,  sarcomatosis.  Massive  enlarge- 
ment of  these  structures  takes  place  in  Hodgkin's  disease.  The  enlarged 
inguinal  glands  in  venereal  disease  and  the  plague  frequently  form  sup- 
purating buboes. 

Neoplasms  of  various  kinds  may  develop  in  the  abdominal  wall.  The 
most  common  variety  is  sarcoma.  In  sarcomatosis  cutis  many  small 
subcutaneous  nodules  appear  scattered  over  the  abdomen.  In  a  recent 
case  a  sarcoma  developed  at  the  umbilicus  and  was  followed,  after  opera- 
tion, in  about  a  year  by  a  small  nodule  in  the  immediate  neighborhood 
and  many  others  in  different  parts  of  the  body. 

Local  Prominences  due  to  Abnormal  Conditions  within  the 
Abdominal  Cavity. — These  conditions  comprise: 

Temporary  Dilatation  of  the  Stomach  from  Excesses  at  Table, 

Gastrectasis, 

Local  Gaseous  Distention  of  the  Bowel,  and  Intussusception. 

Fecal  Accumulations, 

Ectopic  or  Floating  Viscera, 

Visceral  Hypertrophies  and  Enlargements, 

Intra-  and  Perivisceral  Abscess, 

Abscess  from  Caries  of  the  Spine, 

Cysts, 

Extra-uterine  Pregnancy, 

Abdominal  Aneurism, 

Glandular  Enlargements,  and 

Malignant  and  other  New  Growths. 


PHYSICAL  DIAGNOSIS:     INSPECTION. 


81 


Any  of  these  can  exist  without  being  the  occasion  of  prominence 
recognizable  upon  inspection;  but  under  favorable  conditions  this  method 
of  physical  examination  yields  suggestive — even  positive — physical  signs. 
It  is  usually  a  question  of  the  degree  of  their  development  respectively. 

Excessive  fat  and  muscular  rigidity  mask  the  signs  of  these  conditions, 
and  in  the  case  of  great  abdominal  tenderness  a  satisfactory  examination 
is  impossible.  The  plain  recognition  of  an  abdominal  tumor  does  not  in 
all  instances  justify  a  further  diagnosis  of  its  cause  or  nature. 

Gastrectasis. — Temporary  dilatation  of  the  stomach  from  excesses  in 
eating  causes  in  persons  who  are  not  obese  a  visible  prominence  in  the 
epigastric  region.  Substantive  gastrectasis  from  any  cause  shows  a  bulg- 
ing of  the  abdominal  wall  in  the  region  of  the  umbilicus 
or  above  it.  This  bulging  has  downwards  and  to  the 
left  the  outline  of  the  greater  curvature;  if  the  stomach, 
as  is  very  commonly  the  case,  is  displaced  downward 
and  its  longitudinal  axis  more  vertical  than  normal, 
the  outline  of  the  lesser  curvature  may  also  be  visible 
below  the   ensiform   cartilage. 

Intestinal  Obstruction. — The  entire  abdomen  may  be 
distended  or  only  parts  of  it.  If  the  colon  be  distended 
by  hard  fecal  masses  the  course  of  the  bowel  is  marked 
by  an  elongated  eminence,  the  contours  of  which  cor- 
respond to  those  of  the  gut.  If  the  intestinal  stenosis 
be  acute  a  local  area  of  gaseous  distention  without  peri- 
stalsis occurs  above  the  obstruction.  The  obstruction 
may  be  caused  by  fecal  accumulations,  large  gall-stones, 
enteroliths,  or  the  pressure  of  a  tumor.  Any  of  these 
may  give  rise  to  a  distinct,  localized,  asymmetrical 
prominence  of  the  abdominal  wall. 

Intussusception  is  most  common  in  childhood  and 
shows  itself  as  an  elongated  sausage-shaped  tumor  usu- 
ally in  the  region  of  the  caecum  or  at  the  sigmoid  flexure 

Ectopic  or  Floating  Viscera. — General  splanchnop- 
tosis— Glenard's  disease — causes  a  prominence  or  pro- 
trusion of  the  lower  segment  of  the  abdomen  and  is 
common  in  women,  being  favored  by  tight  corsets,  the 
method  of  supporting  the  skirts,  and  the  relaxation  due  to  childbearing. 
Enteroptosis  causes  a  similar  deformity  more  or  less  marked;  gastroptosis 
is  usually  associated  with  dilatation  of  the  stomach.  A  vertical  position 
of  the  stomach  may  be  congenital  or  acquired  as  the  result  of  tighl  Lacing. 
The  pylorus  then  occupies  a  position  in  the  median  line  or  to  the  left  of 
it,  and  the  greater  curvature  lies  below  the  level  of  the  umbilicus.  In  thin 
persons  these  displacements  of  the  organ  may  sometimes  be  demonstrated 
by  the  methods  of  physical  diagnosis,  especially  if  it  be  inflated  with  gas 

followed  by  the  introduction  of  water  through  the  tube  so  that   the  greater 

curvature  may  be  determined  by  dulness  on  percussion  in  sharp  contrasl 
with  the  tympanitic  resonance  of  the  colon. 

Floating  kidney  sometimes  gives  rise  to  an  oval  prominence  plainly 

visible   upon   inspection,   which   may   be   made  to  shift    its   position  or  dis- 
6 


Fig.  4:?. — Viscerop- 
i  Pennsylvania 

Hospital. 


82  MEDICAL  DIAGNOSIS. 

appear  upon  manipulation  or  upon  changes  in  the  posture  of  the  patient, 
^he  swelling  caused  by  a  displaced  kidney  is  usually  upon  its  own  side, 
but  when  very  movable  it  may  sometimes  be  forced  beyond  the  median 
line  to  the  opposite  side.  It  may  occupy  a  position  anywhere  between  the 
ribs  and  the  pelvis  and  is  freely  movable  with  deep  respiration.  Ren 
mobilis  is  much  more  common  in  women  and  upon  the  right  side. 

Floating  Spleen. — The  normal  spleen  which,  in  consequence  of  elonga- 
tion of  the  gastrosplenic  ligament  and  the  splenic  artery  and  veins,  has 
become  dislocated — lien  mobilis — does  not  cause  a  visible  abdominal 
swelling.  When,  however,  the  displaced  organ  is  also  enlarged,  as  is  fre- 
quently the  case,  there  may  sometimes  be  seen  a  rounded  swelling  upon  the 
left  side  in  any  position  from  the  hypochondrium  to  the  pelvis.  This 
swelling,  like  that  caused  by  the  dislocated  left  kidney,  with  which  float- 
ing spleen  is  often  associated,  is  freely  movable  upon  manipulation  and 
change  of  posture. 

Floating  liver  is  among  the  rarest  of  clinical  or  anatomical  findings. 
The  dislocation  of  the  organ  is  usually  slight.  There  is  general  enlarge- 
ment of  the  right  lateral  region  and  a  large  mass  of  characteristic  outline 
which  descends  when  the  patient  assumes  the  erect  posture.  Tympany  in 
the  upper  part  of  the  right  hypochondrium — normal  area  of  liver  dulness — 
disappearing  when  the  organ  is  replaced,  and  the  well-defined  lower  border  of 
the  liver  upon  palpation,  render  the  diagnosis  a  matter  of  comparative  ease. 

Enlargement  of  the  Gall-bladder.  —  This  condition  may  properly  be 
considered  at  this  point,  since  the  position  of  the  enlarged  bladdej  is  very 
different  from  that  of  the  normal  gall-bladder.  The  enlargement  is  the 
result  of  cholecystitis,  frequently  associated  with  cholelithiasis,  or  carcinoma. 

The  gall-bladder  is  distended  by  a  serous  fluid  which  gradually  accumu- 
lates in  consequence  of  the  inflammatory  changes  in  its  walls, — dropsy  of 
the  gall-bladder, — the  bile  no  longer  entering,  because  of  obstruction  of 
the  cystic  duct  by  a  calculus,  a  plug  of  tenacious  mucus,  adhesive  cholan- 
gitis, or  a  carcinomatous  nodule.  In  comparatively  rare  instances  infection 
by  pyogenic  organisms  causes  suppurative  cholecystitis  —  empyema  of 
the  gall-bladder.  If  the  gall-bladder  be  sufficiently  distended  and  the 
abdominal  wall  thin,  there  may  be  seen  an  elongated,  smooth  prominence 
in  the  region  of  the  notch  of  the  liver,  projecting  below  the  liver  margin 
and  rising  and  falling  with  the  respiratory  movements.  The  gall-bladder 
may  be  greatly  distended,  reaching  in  some  instances  the  size  of  the 
fist  or  more.  It  is  then  sometimes  pear-shaped,  the  fundus  being  freely 
movable  from  side  to  side  upon  manipulation  and  change  of  posture. 

In  some  instances  when  the  cholecystitis  is  associated  with  cholelith- 
iasis the  gall-bladder  is  distended  by  an  enormous  accumulation  of  calculi; 
in  others  the  tumor  may  be  due  to  primary  or  secondary  carcinoma  of  the 
gall-bladder. 

Visceral  Enlargements. — The  so-called  corset  liver  may  give  rise  to  a 
visible  prominence  in  the  right  lateral  region,  reaching  as  low  as  the  crest 
of  the  ilium  and  moving  with  respiration.  In  cases  in  which  the  pressure 
constriction  is  marked  the  portion  of  the  liver  below  it  is  movable  and 
may  simulate,  especially  when  a  loop  of  intestine  occupies  the  groove, 
a  displaced  kidney  or  new  growth  in  the  ascending  colon. 


PHYSICAL   DIAGNOSIS:     INSPECTION. 


83 


Enlargement  of  the  liver,  causing  marked  prominence  in  the  right  hypo- 
chondrium,  in  some  cases  of  the  entire  abdomen,  may  be  due  to  hypertrophic 
cirrhosis,  carcinoma,  amyloid  disease,  conditions  causing  obstructive  jaun- 
dice, leukaemia,  syphilis,  hyperemia  due  to  cardiac  disease,  and  fatty  liver. 

Enlargement  of  the  spleen  may  attain  a  considerable  degree  before  it 
gives  rise  to  signs  upon  inspection.     Massive  enlargement   may  occur  in 
chronic  malaria — ague  cake,  leukaemia  and  pseudoleukaeniia.     The  organ 
may  reach  to  the  pelvis  and  even 
to  the  right  of  the  median  line. 

Enlargement  of  the  Kidneys. — 
Renal  tumors  develop  from  behind 
forward,  tending  to  displace  the 
movable  organs  of  the  abdomen, 
especially  the  intestines,  aside. 

The  anatomical  relations  of  the 
ascending  and  descending  colon  are 
such  that  these  portions  of  the  intes- 
tines, being  attached  to  the  kidneys 
by  connective  tissue,  are  retained  in 
front  of  the  growing  renal  tumor  and 
tend  to  obscure  its  dulness  upon 
percussion.  The  development  of  the 
tumor  from  the  upper  portion  of  the 
kidney  causes  a  prominence  of  the 
hypochondrium  on  the  correspond- 
ing side,  which  extends  as  the  growth 
develops  to  the  iliac  region;  the 
development  of  the  tumor  from  the 
lower  portion  of  the  kidney  causes 
prominence  first  in  the  iliac  region. 
Two  .-solid  new  growths  of  the  kidney 
only  are  of  clinical  importance  from 
the  stand-point  of  diagnosis,  namely. 
carcinoma  and  sarcoma.  The  for- 
mer is  more  common  in  advanced 
life,  the  latter  in  childhood;  the  for- 
mer is  apt  to  cause  early  cachexia, 
while  in  the  latter  the  general  nutri- 
tion may  be  maintained;  finally.  Barcomatosis  of  the  skin  in  connection 
with  tumor  of  the  kidney  is  highly  suggestive  as  to  the  nature  of  the 
renal  affection.  Renal  adenoma  cannot  be  differentiated  from  carcinoma 
during  the  life  of  the  patient.     Much  more  rare  is  hypernephroma. 

In  the  rare  cases  in   which   both   kidneys  are  involved  the  abdominal 

enlargement  is  of  course  bilateral. 

The    very   rare   primary    malignant    disease   of   the  suprarenal    capsules 

may  give  rise  to  a  tumor  in  the  hypochondrium  of  the  corresponding  side, 
which  differs  in  no  respect  from  the  similar  manifestation  caused  by  a  tumor 

of  the  upper  half  of  the  kidney.     Renal  tumors  move  only  slightly  or  not 
at   all  wit  h  respiration. 


Fig.  44. —  Massive  enlargement  of  ppleen  in  ■ 
splenomedullary  leukiemia.— Jefferson  Hospital. 


84  MEDICAL  DIAGNOSIS. 

Enlargement  of  the  pancreas  is  caused  by  chronic  pancreatitis  and  car- 
cinoma. It  very  rarely  reaches  such  a  size  as  to  occasion  visible  prominence 
in  the  epigastrium. 

Abscess. — Local  bulgings  of  the  surface  may  be  caused  by  suppurative 
inflammation  in  and  around  the  abdominal  viscera. 

Abscess  of  the  Liver. — Multiple  ab«cess  does  not  usually  reveal  itself 
by  changes  in  the  contour  of  the  surface.  Tropical  abscess  commonly 
causes  the  liver  to  enlarge  upward,  especially  upon  the  right  side.  The 
respiratory  excursus  is  diminished  or  absent  and  the  lower  intercostal 
spaces  obliterated.     There  is  often  local  oedema. 

Subphrenic  abscess  occasions  marked  downward  displacement  of  the 
liver  and  a  smooth,  soft  tumor  in  the  epigastrium.  If,  as  is  commonly 
the  case,  there  is  air  as  well  as  pus  in  the  subphrenic  space,  the  diagnosis  is 
not  attended  with  difficulty. 

Abscess  of  the  spleen,  when  of  sufficient  size,  sometimes  reveals  itself 
by  a  splenic  tumor,  upon  the  surface  of  which  a  fluctuating  area  or  areas 
may  be  obscurely  felt  through  a  thin-walled  abdomen. 

Renal  abscess  may  cause  a  circumscribed  tumor  in  the  hypochondrium 
or  iliac  region  of  the  affected  side,  with  obscure  fluctuation,  but  without 
oedematous  swelling  of  the  neighboring  tissues. 

Perinephritic  Abscess. — The  swelling  occupies  the  lumbar  region  and 
there  is  oedema  of  overlying  and  adjacent  parts.  There  is  frequently 
■burrowing  of  the  pus  in  a  downward  direction,  so  that  a  second  fluctuating 
tumor  may  be  present  at  a  more  dependent  point. 

Abscess  in  Appendicitis. — The  common  situation  of  the  large,  circum- 
scribed intraperitoneal  abscess  is  in  the  iliac  region  between  the  navel  and 
the  anterior  superior  spine.  The  abscess  may  form  in  the  retroperitoneal 
space  and  burrow  beneath  the  iliac  fascia,  showing  itself  at  Poupart's 
ligament,  or  it  may  accumulate  in  the  retroperitoneal  tissue  in  the  flank, 
forming  a  large  paranephritic  abscess,  with  the  usual  oedematous  condition 
of  the  surrounding  parts. 

Abscess  from  caries  may  follow  enteric  fever  and  show  itself  as  a  small 
fluctuating  tumor  overlying  a  rib  or  costal  cartilage.  Vertebral  caries  may 
cause  an  abscess  in  the  lumbar  region,  or  the  pus  may  follow  the  sheath 
of  the  psoas  muscle  and  point  below  Poupart's  ligament — psoas  abscess. 

Ovarian  or  tubal  abscess  may  give  rise  to  distention  in  the  iliac  region 
of  either  side.  When  upon  the  right  side  these  conditions  may  simulate 
appendiceal  abscess,  with  which  they  are  also  occasionally  associated. 

Cysts. — Local  as  well  as  general  prominence  may  be  caused  by  cysts 
of  various  kinds.  If  large  the  distention  is  general,  if  small  it  is  local  and 
circumscribed.  From  a  pathologico-anatomical  beginning  wholly  without 
symptoms  and  unrecognizable,  certain  cysts  frequently  attain  enormous 
dimensions.  Among  these  are  especially  to  be  mentioned  cysts  of  the 
pancreas,  hydronephrosis,  and  ovarian  cysts;  which  are  often  of  such  size 
as  to  simulate  ascites.  The  smaller  cysts  do  not  present  physical  signs 
which  differentiate  them  from  abscesses  in  the  same  localities.  It  is  only 
by  a  general  knowledge  of  the  pathological  processes  which  give  rise  to 
cyst-  and  abscess-formation  respectively  and  a  careful  consideration  of 
the   anamnesis  and   associated   symptoms  that   the   differential   diagnosis 


PHYSICAL  DIAGNOSIS:     INSPECTION.  85 

can  in  some  instances  be  made  out,  as  in  dropsy  and  empyema  of  the 
gall-bladder,  echinococcus  and  abscess  of  the  spleen,  or  hydro-  and  pyo- 
nephrosis. Cysts  springing  from  the  liver,  dropsy  of  the  gall-bladder, 
echinococcus  and  pancreatic  cysts  have  their  early  manifestations  in  the 
upper  regions  of  the  abdomen — epigastric  zone — to  the  right  and  left  of 
the  median  line  respectively;  those  springing  from  the  kidney — hydrone- 
phrosis, echinococcus — first  appear  in  the  lateral  regions,  while  those  from 
the  pelvic  organs,  ovarian  cysts,  hydramnion,  arise  from  the  pelvis — hypo- 
gastrium.  Mesenteric  cysts  are  usually  situated  to  the  right  of  the  umbil- 
icus and  below  its  level.  Cysts  connected  with  the  liver  and  spleen  are 
influenced  by  the  respiratory  movements;  those  connected  with  the  pan- 
creas only  slightly  or  not  at  all,  and  those  developing  from  the  kidneys, 
ureters,  and  pelvic  organs  remain  unaffected  by  the  respiratory  movements 
of  the  diaphragm. 

Aneurism. — Aneurism  of  the  abdominal  aorta  may  cause  a  distinct, 
pulsating  tumor  commonly  in  the  epigastrium  but  occasionally  to  the 
left  of  the  median  line  in  front  or  in  the  lumbar  region.  This  tumor  is  almost 
always  immovable,  but  in  rare  instances  has  been  influenced  by  manipula- 
tion and  change  of  posture,  but  not  by  respiration.  It  presents  the  signs 
of  aneunsm,  and  is  to  be  differentiated  from  tumors  overlying  the  aorta 
and  from  the  so-called  "dynamic  pulsation"  of  the  aorta  which  occurs 
in  neurotic  individuals.  The  distended  urinary  bladder  in  urethral  stric- 
ture, impacted  calculus,  etc.,  gives  rise  to  a  distinct  rounded  oval  tumor  of 
the  hypogastrium.  which  reaches  in  extreme  cases  well  up  towards  the 
umbilicus.  To  a  less  extent  the  retention  of  the  low  fevers  and  comatose 
conditions  gives  rise  to  a  similar  prominence.  In  the  latter  case,  the  incon- 
tinence of  retention — stUlicidium  urinm — prevents  extreme  distention. 
The  anamnesis,  the  oval  outline  of  the  tumor,  its  central  and  symmetrical 
situation,  fluctuation, and  its  immediate  disappearance  upon  catheterization 
render  the  diagnosis  clear. 

Extra-uterine  Pregnancy.  — There  is  a  history  of  morning  nausea, 
paroxysmal  colicky  pain  with  faintness,  enlargement  and  hardness  of  the 
breasts,  and  chloasma  uterinum,  together  with  the  presence  of  a  prominence 
to  the  right  or  left  of  the  median  line  above  the  brim  of  the  pelvis.  Very 
often  rupture  of  the  sac  takes  place  before  it  has  attained  sufficient  enlarge- 
ment to  be  recognized  by  the  methods  of  physical  diagnosis.  This  accident 
is  attended  by  collapse  symptoms,  and  upon  vaginal  examination  the  uterus 
is  found  to  be  somewhat  enlarged  and  displaced  downward  and  to  the 
Opposite  side. 

Glandular  Enlargements. —Enlargement  of  the  retroperitoneal  glands. 
usually  sarcomatous—  Lobstein's  cancer — may  cause  a  visible  tumor  in 
the  epigastric  or  umbilical  region,  usually  tense,  immovable,  and  nodular; 
sometimes  slightly  movable  and  obscurely  fluctuating  and  crossed  by 
the  colon,  which  may  be  recognized  upon  palpation  or  by  its  tympanitic 
resonance,  to  secure  which  artificial  inflation  may  be  necessary.  Tuber- 
culous mesenteric  glands — tabes  mesenterica — cause,  especially  in  children, 
marked  protrusion  of  the  abdomen  with  tympany.  The  enlarged  lymphatic 
glands  may  cause  irregular  local  prominence  in  the  region  of  the  navel  or 
in  the  right  iliac  fossa  and  may  be  recognized  upon  palpation. 


86 


MEDICAL  DIAGNOSIS. 


Malignant  and  Other  New  Growths. — Malignant  diseases  of  abdominal 
organs — carcinoma,  sarcoma — are  of  chief,  while  benign  affections,  fibroma, 
lipoma,  myxoma,  adenoma,  and  gumma,  are  of  subordinate  interest  from  the 
stand-point  of  diagnosis.  This  difference  is  to  be  ascribed  not  only  to  the 
greater  frequency  of  the  former  and  their  disastrous  effects  upon  the  health 
and  ultimately  upon  the  life  of  the  patient,  but  also  to  the  fact  that  at 
some  time  in  their  course  the  diagnosis  becomes  both  practicable  and  ob- 
vious, while  in  the  latter  with  less  significant  symptoms  the  diagnosis  cannot 
be  made  out  and  the  condition  often  remains  unsuspected  during  the  whole 

course  of  the  patient's  life  and  only 
assumes  pathologico-anatomical 
interest  when  the  case,  death  hav- 
ing resulted  from  an  entirely  dif- 
ferent disease,  at  length  comes  to 
autopsy.  It  is  of  diagnostic  impor- 
tance that  in  visceral  as  well  as  in 
external  cancer,  secondary  implica- 
tion of  adjacent  and  distant  organs 
takes  place  with  characteristic  signs 
and  that  ultimately  in  many  cases 
the  superficial  lymphatic  glands 
become  enlarged,  nodules  appear  in 
the  skin  and  elsewhere — general  car- 
cinomatosis, general  sarcomatosis. 
Cancer  of  the  Stomach. — The 
tumor  can  be  seen  in  some  cases, 
but  is  usually  only  to  be  recognized 
upon  palpation.  It  most  com- 
monly occupies  the  region  of  the 
pylorus  and  may  be  slightly  mov- 
able with  respiration  and  freely  so 
upon  manipulation.  A  visible 
tumor  occupying  the  greater  part  of 
the  epigastrium  and  even  extending 
beyond  its  borders,  irregular,  nod- 
ular, well  defined  at  its  margin, 
immovable  and  very  distinct  through  the  emaciated  wall  of  the  belly,  is 
sometimes  present  in  advanced  cases  of  carcinoma  extensively  involving 
the  anterior  wall  of  the  stomach. 

Cancer  of  the  Liver. — The  volume  of  the  organ  is  usually  greatly  in- 
creased. The  increase  is  rapid  and  may  assume  enormous  dimensions. 
It  may  affect  the  entire  liver  or  the  right  or  left  lobe  to  a  preponderating 
extent.  When  the  right  lobe  is  chiefly  involved,  there  is  a  flaring  out  of 
the  lower  ribs  and  costal  cartilages;  when  the  left,  the  appearance  of  the 
tumor  may  suggest  a  new  growth  involving  the  greater  curvature  of  the 
stomach,  a  cyst  of  the  pancreas,  or  an  enlarged  spleen,  but  these  doubts  are 
immediately  set  at  rest  by  palpation  and  percussion.  The  surface  is  usually 
uneven  and  the  border  irregular,  and  these  signs  may  in  some  cases  be 
clearly  made  out  upon  inspection.    In  the  absence  of  adhesions  the  respira- 


Fig.  45. — Sarcomatosis  cutis, — primary  tumor 
springing  from  a  pigmented  mole  on  the  forehead; 
metastatic  growths  appeared  in  a  few  months  after 
primary  growth. — Jefferson  Hospital. 


PHYSICAL  DIAGNOSIS:     INSPECTION.  87 

tory  excursus  of  the  liver  may  be  seen,  and  in  one  remarkable  case  in  my 
service  at  the  Philadelphia  Hospital,  when  upon  autopsy  the  entire  right 
lung  was  found  to  be  solidified  by  secondary  carcinomatous  infiltration, 
the  respiratory  movement  of  the  liver,  plainly  seen  through  the  abdominal 
wall,  was  from  left  to  right  upon  inspiration.  When,  as  is  often  the  case, 
extensive  adhesions  are  present,  respiratory  movement  of  the  enlarged 
liver  does  not  take  place  Multilocular  echinococcus  and  gumma  of  the 
liver  present  great  difficulties  in  diagnosis.  Splenic  enlargement  in  the 
former  and  a  history  of  lues  in  the  latter  are  significant.  An  individual 
who  has  syphilis  may  also  be  the  subject  of  echinococcus  disease. 

Cancer  of  the  Gall-bladder. — The  position  of  the  tumor  and  its  respira- 
tory movement  are  important.  It  is  apt  to  be  mistaken  for  cancer  of  the 
pylorus  or  duodenum.  In  the  latter  affections,  when  the  cancer  is  primary, 
free  hydrochloric  acid  may  be  wanting  in  the  gastric  contents,  secondary 
dilatation  of  the  stomach  shortly  appears,  and  the  tumor  may  be  made  out 
to  be  connected  with  the  stomach  or  bowel  by  dilating  the  stomach,  with 
simultaneous  percussion  and  palpation,  while  the  seat  of  the  tumor  in  the 
gall-bladder  becomes  at  the  same  time  more  obvious  by  its  shape  and 
relatively  superficial  situation. 

A  tumor  formed  by  cancer  of  the  head  of  the  pancreas  cannot  often  be 
positively  differentiated  from  cancer  of  the  pylorus,  duodenum,  transverse 
colon,  or  porta  hepatis.  At  best  in  a  majority  of  cases  the  diagnosis  must 
be  made  by  exclusion. 

Inspection  of  the  Surface  of  the  Abdomen.  Abnormal  Signs.  — 
Moderate  ascites  and  large  tumors  may  be  present  without  changes  in  the 
integument;  but  excessive  distention  causes  nutritive  changes  and  the 
skin  loses  its  natural  appearance,  becoming  tense,  glistening,  and  thinned. 
White  lines  or  stria? — linea?  albicantes — irregularly  parallel  and  slightly 
depressed  below  the  adjacent  surface  are  produced  by  extreme  or  prolonged 
distention,  as  in  pregnancy,  obesity,  and  ascites.  They  are  seen  upon  the 
abdomen,  flanks,  and  thighs,  and  persist  after  the  condition  which  caused 
thorn  has  passed  away.  Jaundice  is  often  more  conspicuous  here  than  on 
surfaces  exposed  to  the  air.  Striking  deposits  of  pigment  occur  in  the 
linea  alba  in  pregnancy,  especially  in  brunettes,  and  pigmentation  due  to 
abdominal  growths  and  diseases  of  the  peritoneum,  Addison's  disease, 
melanotic  cancer,  exophthalmic  goitre,  scleroderma,  arteriosclerosis,  and 
chronic  heart  disease  is  often  conspicuous  upon  the  abdomen,  especially 
in  the  lower  quadrants  and  about  the  flexures  of  the  thighs.  The  pigmen- 
tation of  vagabondage  due  to  lice  and  filth  is  usually  characterized  by  the 
parallel  linear  superficial  lesions  of  scratching.  The  hemochromatosis  of 
hypertrophic  cirrhosis  and  diabetes  and  in  rare  instances  scleroderma  are 
attended  by  conspicuous  pigmentation.  The  prolonged  administration 
of  arsenic  frequently  causes  marked  discoloration  of  the  skin.  The  general 
discoloration  of  argyria  is  less  pronounced  upon  the  surface  of  the  trunk 
than  upon  the  face  and  extremities.  The  specific  eruptions  of  the  exan- 
themata, especially  the  initial  rashes  of  variola, and  t  he  rose  spots  of  enteric 
fever  are  to  be  sought  for  upon  the  abdomen.  Tache  bleuatres,  tinea 
versicolor,  and  the  symmetrical  diffuse  macular  eruption  of  secondary 
syphilis  are  to  be  seen.     The  scars  of  surgical  operations,  especially  those 


MEDICAL  DIAGNOSIS. 


performed  for  the  relief  of  appendicitis,  gastric  and  gall-bladder  disease, 
and  various  diseases  of  the  pelvic  organs  are  common  nowadays  and  may 
shed  light  upon  many  abdominal  disorders — adhesions  and  the  like — post- 
operative neurasthenia  and  other  obscure   maladies.     Enlarged  inguinal 

glands  and  retracted  cicatrices 
in  the  groins  may  be  significant 
of  venereal  infection. 

Vascular  Changes. — Signs  relat- 
ing to  circulatory  derangements  are 
enlarged  superficial  epigastric 
arteries  and  enlarged  superficial 
veins.  The  former  are  exceed- 
ingly rare  and  indicate  obstruction 
of  the  aorta  or  iliac  arteries;  the 
latter  very  common  and  constitute 
the  evidence  of  collateral  venous 
circulation  in  obstruction  of  the 
portal  system  or  the  inferior  or 
superior  vena  cava.  Among  the 
common  causes  of  such  obstruction 
are,  in  the  portal  circulation,  cir- 
rhosis of  the  liver  and  tumor;  in 
the  general  circulation,  abdominal 
and  mediastinal  tumor,  dilatation 
of  the  stomach  of  high  grade,  and 
ascites  of  long  standing. 

Caput  medusae  is  a  varicose 
arrangement  of  the  dermal  veins 
around  the  umbilicus  with  radiat- 
ing branches.  It  is  made  up  by  the 
dilated  branches  of  the  epigastric 
veins  at  their  juncture  with  a  large 
single  vein  which  passes  from  the 
hilum  of  the  liver  and  follows  the 
course  of  the  round  ligament — 
para-umbilical  vein  of  Sappey. 
Much  more  commonly  the  enlarged 
collateral  veins  are  distributed 
irregularly  over  the  surface  of  the 
abdomen  and  indicate  one  of  the 
courses  towards  the  right  heart 
taken  by  the  blood  in  pressure 
upon  the  inferior  vena  cava.  There  is  engorgement  of  the  blood  from 
the  lower  extremities  in  the  inferior  epigastric  and  internal  mammary 
veins,  with  dilatation  of  the  superficial  abdominal  veins.  In  obstruc- 
tion of  the  portal  system  and  inferior  vena  cava  the  course  of  the 
blood  in  the  dilated  superficial  veins  is  upward;  when  the  superior  cava 
is  obstructed  the  course  of  the  blood  in  the  superficial  veins  of  the  chest 
and  abdomen  is  downward,  the  blood  seeking  its  way  to  the  right  heart 


Fig.  40. — Sarcoma  of  spine,  showing  venous  stasis  and 
metastatic  growth  in  orbit. — Young. 


PHYSICAL  DIAGNOSIS:     INSPECTION.  89 

by  means  of  the  right  azygos  which  communicates  with  various  tributaries 
of  the  inferior  vena  cava.  Pressure  upon  the  innominate  vein  of  the  right 
or  left  side  may  give  rise  among  other  signs  to  great  dilatation  of  the 
superficial  veins  of  the  thorax  and  abdominal  wall. 

The  Umbilicus.  —  The  navel  normally  shows  transverse  or  slightly 
spiral  folds  of  the  skin  and  is  moderately  retracted.  It  is  deeply  so  and 
funnel-shaped  in  obese  persons  and  level  with  the  surrounding  surface  or 
protruding  in  large  ascites  and  pregnancy.  It  may  be  the  seat  of  caput 
medusas  or  hernia,  inflammation  or  eczema,  carcinoma  secondary  to  gastric 
carcinoma  or  tuberculous  infiltration  secondary  to  tuberculous  peritonitis 
A  mole  in  the  region  of  the  umbilicus  may  undergo  sarcomatous  changes. 

Movements  of  the  Abdomen  in  Disease.  —  Inspiratory  retraction 
of  the  epigastrium  is  present  in  stenosis  of  the  upper  air-passages  and 
imperfect  action  of  the  diaphragm.  Diminished  respiratory  movement 
of  the  abdomen  may  be  caused  by  upward  pressure  upon  the  diaphragm, 
as  in  tympany,  ascites,  and  abdominal  tumors  on  the  one  hand,  or  by  mas- 
sive pleural  or  pericardial  effusions  on  the  other.  In  the  early  stages  of 
peritonitis  abdominal  respiratory  movement  is  greatly  impaired  or  whollv 
absent,  on  account  of  the  pain  and  tonic  contraction  of  the  muscles  of  the 
wall;  in  the  later  stages  on  account  of  the  tympany  and  upward  pressure 
upon  the  diaphragm. 

Visible  Peristalsis. — In  thin  persons  the  normal  peristaltic  movements 
may  sometimes  be  seen.  They  appear  as  wave-like,  rounded  elevations  of 
the  surface  which  may  be  attended  by  borborygmi  and  may  be  intensified 
by  gentle  irritation  of  the  skin  by  the  application  of  cold,  brisk  tapping  or 
faradism.  In  some  instances  the  peristaltic  movements  of  the  stomach 
from  left  to  right  are  in  sharp  contrast  to  those  of  the  transverse  colon  from 
right  to  left.  In  the  wide  separation  of  the  recti  occasionally  seen  in  women 
who  have  borne  many  children  these  vermicular  movements  are  very 
conspicuous. 

The  most  important  diagnostic  significance  of  visible  peristalsis  relates 
to  intestinal  obstruction.  The  presence  of  peristalsis  must  be  determined 
and  whether  or  not  it  is  always  in  the  same  direction  and  ceases  at  a  certain 
spot.  If  the  obstruction  is  at  or  above  the  ileocecal  valve  the  distended 
and  mobile  coils  of  small  intestine  occupy  a  position  in  the  central  portion 
of  the  abdomen,  but  if  the  obstruction  involves  the  lower  part  of  the  large 
intestine — sigmoid  flexure — the  distention  and  movements  of  the  bowel 
may  be  manifest  in  the  region  occupied  by  the  ascending  and  transverse 
colon.  The  inflated  fixed  intestinal  coil  of  acute  stenosis  of  the  gut,  ileus — ■ 
strangulated  hernia — shows  no  peristaltic  movement.  Prior  to  immobility 
there  is  peristalsis.  In  chronic  obstruction,  after  the  muscularis  of  the 
gut  has  become  hypertrophied,  there  is  active  peristalsis,  with  marked 
recurrent  tumor  subsiding  with  coarse  borborygmi.  just  in  advance  of  the 
stenosis.  As  the  gas  in  the  tumor  is  under  tension,  it  does  not  yield  tym- 
panitic resonance  but  dulness  upon  percussion.  Visible  peristalsis  in  the 
left  hypochondrium,  with  the  vermicular  contractions  from  left  to  right, 
has  been  observed  in  extreme  gastrectasis. 

Pulsation  Synchronous  with  the  Cardiac  Systole.  —  Dynamic  pulsation 
occurs  in  neurotic  persons.    It  is  seen  in  the  median  line  and  is  often  violent 


90 


MEDICAL  DIAGNOSIS. 


but  neither  diffuse  nor  expansile.  The  pulsation  of  abdominal  aneurism 
usually  has  both  these  characters  and  very  often  in  addition  systolic 
thrill   and   bruit.     It  is   mostly  situated    in   the    median  line,  but   may 

be  seen  in  the  left  lateral  region 
of  the  abdomen. 

An  Aid  to  Inspection  in  Cir- 
cumscribed Movements  not  Well 
Defined. — 1  have  found  the  fol- 
lowing suggestion  of   K.  H.  Beall 


of  much  service: 

"Over  the  area  under  inspec- 
tion there  is  drawn  with  a  skin 
pencil  a  square  plaid  figure,  the 
squares  of  which  are  from  1.5  to 
2.5  cm.  in  diameter  and  from  12 
to  50  in  number,  according  to  the 
size  of  the  area  being  studied. 
Any  slight  movement  of  the  skin 
at  any  point  in  such  a  marked  area 
causes  a  change  in  the  direction  of 
some  of  the  lines  and  a  distortion 

of  the  figure,  and  so  renders  visible  movements  of  the  internal  organs 

which  are  not  to  be  detected  otherwise. " 


Fig.  47. — Beall's  aid  to  inspection. 


PALPATION. 

The  method  of  physical  diagnosis  in  which  the  sense  of  touch  is  em- 
ployed is  known  as  palpation.  It  consists  in  the  systematic  examination 
of  the  surface  of  the  chest  and  abdomen  by  the  laying  on  of  the  hand. 
The  physical  signs  elicited  depend  upon  the  condition  and  movements  of 
the  parts  and  the  underlying  structures.  As  in  inspection,  we  study  the 
form,  size,  condition  of  the  surface,  and  movements.  The  method  is  appli- 
cable and  essential  to  the  examination  of  the  thorax  and  abdomen. 


Palpation  in  the  Examination  of  the  Thorax. 

The  chest  should  be  bared,  the  attitude  easy,  the  arms  symmetrically 
disposed,  the  muscles  relaxed.  The  examining  hand  should  be  warm  and 
laid  gently  upon  the  surface.  The  amount  of  pressure  employed  must  be 
determined  in  individual  cases.  Ticklishness,  tenderness,  and  excessive 
fat  constitute  obstacles.  The  first  may  be  overcome  by  care  and  diverting 
the  attention  of  the  patient;  the  others  often  amount  to  insuperable  diffi- 
culties in  the  application  of  this  method  of  diagnosis.  The  palmar  surface 
of  the  whole  hand  is  employed  for  a  general  survey,  as  in  locating  the  posi- 
tion of  the  cardiac  impulse  or  a  thrill;  the  more  sensitive  finger  tips  for  the 
study  of  the  particular  characters  of  such  phenomena,  for  example  the  force 
and  extent  of  the  impulse  or  the  coarseness  or  fineness  and  extent  of  a  thrill. 

By  palpation  we  confirm  and  amplify  the  signs  obtained  by  inspec- 
tion, especially  those  dependent  upon  the  form  and  contour  of  the  chest, 


PHYSICAL  DIAGNOSIS:    PALPATION.  91 

the  width  of  the  interspaces,  the  presence  of  local  swellings  and  deformi- 
ties, and  the  respiratory  and  cardiac  movements.  These  it  is  not  necessary 
at  this  point  to  repeat.  But  there  are  other  physical  signs,  not  always 
recognizable  upon  inspection,  which  we  investigate  by  palpation.  These 
comprise  the  condition  of  the  wall  of  the  chest  as  regards 

Muscular  Tension, 
(Edema, 

Width  of  the  Interspaces, 

Fluctuation, 

Nodes.  Gummata,  and  Periosteal  Thickening, 

Location  and  Character  of  the  Heart's  Impulse. 

Extracardial    Pulsation  and   Diastolic   Shock,   and  in    particular  the 

following  physical   signs  which  are  exclusively  within  the  scope 

of  this  method: 
The  Crepitation  of  Subcutaneous  Emphysema, 
Thrills.  Cardiac  and  Vascular, 
Fremitus,  Vocal,  Friction,  and  Rhonchal, 
Tracheal  Tugging. 


i&&* 


Tension. — The  tension  of  the  muscular  wall  of  the  chest  in  the  inter- 
costal spaces  and  about  the  ensiform  cartilage  is  not  a  sign  of  great  value, 
yet  it  is  to  be  studied  in  doubtful  cases.  The  inspiratory  retraction  of  the 
base  of  the  chest  is  a  sign  of  obstruction  to  the  entrance  of  air,  which  may 
be  at  the  larynx,  as  in  cedema  of  the  glottis,  or  in  the  smallest  bronchial 
tubes,  as  in  bronchopneumonia.  The  slight  normal  furrow  of  the  lower 
intercostal  spaces  may  be  obliterated  by  pleural  or  pericardial  effusion  or 
a  rapidly  growing  new  growth.  In  old  empyemata  there  is  great  relaxa- 
tion and  bulging  and  the  cardiac  pulsations  may  even  be  transmitted  to 
the  surface — pulsating  empyema.  Epigastric  rigidity  and  tenderness  are 
conspicuous  in  tetanus,  and  these  phenomena  are  early  symptoms  in 
peritonitis  beginning  in  the  upper  part  of  the  abdomen. 

(Edema. — Local  oedema  may  indicate  intrathoracic  suppuration  as 
in  empyema  or  hepatic  abscess,  inflammation  of  the  wall  of  the  chest  as 
in  carbuncle,  or  obstruction  to  the  venous  circulation  as  in  mediastinal 
tumor  or  aneurism.  The  pufhness  involves  the  head  and  neck  on  both 
sides  when  the  pressure  involves  the  precava  and  is  unilateral  when  it 
affects  the  right  or  left  innominate  only. 

Spaces.  The  width  of  the  intercostal  spaces  may  be  felt  when  not 
seen  upon  inspection,  and  should  be  carefully  investigated  in  cases  of  pleu- 
ral effusion,  since  they  are  wide  when  the  chest  is  distended  and  become 
narrow  as  the  fluid  undergoes  resorption. 

Fluctuation.  Elasticity  or  fluctuation  in  any  prominence  or  tumor 
upon  the  surface  of  the  chest  is  an  importanl  sign.  It  may  be  due  to  abscess 
of  the  wall  itself,  empyema  necessitatis,  cyst  formation,  or  sarcoma.  The 
differential  diagnosis  rests  upon  the  associated  clinical  phenomena.  In 
abscess  of  the  wall  the  volume  of  the  tumor  is  not  affected  by  the  respira- 
tory movements;  in  empyema  necessitatis  the  tumor  diminishes  upon 
inspiration  and  increases  with  expiration  and  the  physical  signs  of  intra- 


92  MEDICAL  DIAGNOSIS. 

pleural  effusion  are  present;  a  cyst  is  usually  sharply  circumscribed, 
distinctly  globular,  tense,  sometimes  translucent,  and  commonly  movable 
within  a  limited  range. 

Nodes. — Nodes  upon  the  ribs,  cartilages,  or  sternum  or  thickening 
at  the  chondrocostal  or  sternoclavicular  articulations  and  periosteal  thick- 
ening are  important  signs  of  disease.  They  may  sometimes  be  felt  when 
not  obvious  upon  inspection,  and  their  size  and  consistence  can  be  recog- 
nized upon  palpation.  Among  the  earliest  of  the  skeletal  lesions  of  rickets 
is  a  nodular  enlargement  of  the  ribs  at  the  juncture  of  the  bone  with  the 
cartilage.  These  nodules  are  present  upon  the  ribs  of  both  sides  and  are 
symmetrical  in  their  arrangement — the  so-called  rosary  of  rickets.  Gum- 
mata  are  common  upon  the  sternum  and  roughening  and  enlargement  of 
the  clavicles  may  be  a  manifestation  of  late  syphilis.  The  clavicles  are 
enlarged  and  the  sternum  deformed  in  acromegaly.  Acute  painful  enlarge- 
ment of  the  sternoclavicular  articulation  is  not  rare  in  gonorrhoeal  arthri- 
tis. A  soft,  elastic,  slightly  fluctuating  tumor  upon  the  upper  part  of  the 
sternum  may  be  a  tuberculous  abscess.  Tender  points  are  found  upon 
palpation.  They  are  not  physical  signs,  but  may  be  mentioned  in  this 
connection  as  symptoms  of  great  value.  They  are  found  in  intercostal 
neuralgia  and  correspond  to  the  points  of  emergence  of  the  intercostal 
nerves;  in  neurasthenia  tender  points  are  also  found  along  the  dorsal  spine 
and  the  tenderness  is  very  often  present  upon  light  and  absent  upon  firm 
pressure;  in  necrosis  of  a  rib;  in  fibrinous  pleurisy  and  especially  in 
that  form  of  pleurisy  which  occurs  in  pulmonary  tuberculosis,  where  the 
tenderness  is  most  common  and  most  marked  in  the  infraclavicular  region. 

Apex=beat. — The  precise  location  and  character  of  the  impulse  of 
the  heart.  The  palm  of  the  hand  should  be  first  laid  over  the  precordia 
below  the  left  nipple.  The  signs  elicited  by  inspection  are  thus  confirmed 
and  amplified.  We  determine  whether  the  rhythm  of  the  heart  is  regular 
or  irregular  and;  if  irregular,  whether  the  arrhythmia  is  in  time  or  in  force 
or  both,  that  is,  whether  there  are  differences  in  the  intervals  between 
the  ventricular  contractions,  or  in  the  power  with  which  the  heart  con- 
tracts or  these  are  combined.  We  observe  also  in  this  way  the  general 
character  of  the  heart's  action,  that  is,  feeble  or  strong;  heaving  power- 
fully so  as  to  move  the  whole  chest,  as  in  great  hypertrophy  or  the  over- 
action  of  mental  or  physical  excitement — palpitation;  that  it  has  the 
diffuse  slap  often  encountered  in  dilatation  of  the  right  ventricle,  the  sharp 
tap  of  mitral  stenosis  or  the  slow,  heaving,  forcible  impulse  sometimes 
met  with  in  aortic  stenosis. 

The  more  sensitive  tips  of  the  fingers  are  next  brought  into  service. 
They  are  placed  over  the  point  of  maximum  impulse  and  moved  in  vari- 
ous directions.  The  apex  of  the  heart  as  determined  by  finger-tip  palpa- 
tion and  by  percussion  is  usually  two  or  three  centimetres  below  and  to 
the  left  of  the  point  of  maximum  or  visible  impulse.  It  frequently  happens 
that  the  impulse  not  recognized  upon  inspection  may  be  felt  and  rarely 
that  a  visible  impulse  cannot  be  appreciated  by  the  trained  touch.  These 
two  methods  must  be  used  in  all  cases. 

Inspection  and  palpation  yield  the  most  satisfactory  results  in  the 
study  of  the  size  of  the  heart.     The  base  of  the  organ  is  fixed  and  is  as  a 


PHYSICAL  DIAGNOSIS:    PALPATION.  93 

rule  not  greatly  displaced  even  by  the  pressure  of  an  aneurism  or  new 
growth.  To  fix  the  position  of  the  apex  is  to  determine  the  long  axis  of 
the  heart  and  gain  a  fairly  correct  idea  of  its  size.  The  data  obtained  by 
percussion  are  much  less  definite,  partly  because  of  inherent  difficulties 
in  recognizing  the  limits  of  dulness  in  the  rounded  body  of  the  heart  sur- 
rounded by  resonant  lung  and  partly  because  of  the  modifying  effects  of 
pleural  adhesions  or  effusion,  gastric  dilatation  or  abdominal  tympany. 
When  the  impulse  cannot  be  located  by  inspection  or  palpation,  we  employ 
auscultation  and  consider  the  clinical  impulse  to  be  near  the  point  at  which 
the  first  sound  is  most  distinctly  heard. 

The  changes  in  the  relation  of  the  apex  to  the  wall  of  the  chest  caused 
by  changes  in  the  posture  of  the  patient  have  already  been  considered. 

Extracardiac  Pulsation.  —  Pulsation  beyond  the  limits  of  the 
heart  is  frequently  seen,  but  its  precise  location,  extent,  and  character 
are  best  studied  by  the  sense  of  touch.  A  heaving  impulse  at  the  root 
of  the  neck  occurs  in  hypertrophy,  especially  that  form  associated  with 
aortic  insufficiency  and  in  overaction  from  nervous  causes.  It  occurs 
also  in  anaemia  and  large  hemorrhages,  in  apoplexy,  and  rarely  in  the 
stage  of  onset  of  intense  infections,  as  variola.  It  is  a  conspicuous  phenom- 
enon in  exophthalmic  goitre.  In  neurotic  persons  the  pulsating  dilated 
transverse  aorta  may  in  rare  instances  be  felt  in  the  sternal  notch — 
dynamic  pulsation.  Aneurism  of  the  innominate  artery  or  of  the  trans- 
verse portion  of  the  aortic  arch  may  give  rise  to  similar  pulsation.  Anom- 
alies in  the  distribution  of  the  subclavian  or  thyroid  arteries  may  also  give 
rise  to  pulsation  in  this  region.  In  old  pleural  adhesions  at  the  apex  and 
in  pulmonary  tuberculosis  subclavian  pulsation  is  often  marked  and 
extended.  Pulsation  commonly  to  the  right  of  the  manubrium,  some- 
times to  the  left  of  it,  occurs  in  aneurism  of  the  thoracic  aorta  and  may 
often  be  felt  when  it  is  not  seen.  The  force  and  extent  of  the  impulse  in 
pulsating  empyema  arc  best   estimated  by  palpation. 

Epigastric  Pulsation.  —  This  phenomenon  is  generally  regarded  as 
the  sign  of  hypertrophy  of  the  right  ventricle  and  this  view  is  unquestion- 
ably in  some  cases  correct.  The  hypertrophied  and  overacting  righl 
heart  communicates  its  movements  to  the  tissues  at  the  tip  of  and  below 
the  ensiform  cartilage.  The  retraction  corresponds  to  time  with  the  ven- 
tricular systole  and  is  due  to  the  negative  pressure  caused  by  the  altera- 
tion in  size  and  diminution  in  the  volume  of  the  ventricles  al  this  moment 
of  the  heart's  revolution.  Epigastric  pulsation  has  been  observed  in  cases 
in  which  no  hypertrophy  of  the  right  ventricle  has  been  found  posl  mor- 
tem. Liver  pulsation  is  much  more  frequently  palpable  than  visible,  and 
the  distinction  between  this  condition  and  a  liver  jogged  by  an  overacting 

heart  may  often  be  made  by  bimanual  palpation,  since  a  pulsating  liver 
expands  and  contracts,  a  jogged  liver  merely  moves.     Bimanual  palpation. 

one  hand  upon  the  upper  dorsal  spine  and  the  Other  upon  the  manubrium. 
may  detect  the  expansile  pulsation  of  a  deep-seated  aortic  aneurism  which 
presents  no  external  signs.  Diastolic  shock  is  an  important  physical  sign 
of  aneurism.  The  tips  of  the  fingers  upon  the  sac  in  case  erosion  of  the 
chest  wall  has  taken  place,  or  upon  the  surface  directly  overlying  the  sa  •. 

may  often  detect   a  diastolic  shock,  sometimes  Of  considerable  force. 


94  MEDICAL  DIAGNOSIS. 

Crepitation. — In  wounds  and  operations  upon  the  neck  and  chest 
air  may  find  its  way  into  the  subcutaneous  tissues  and  give  rise  to  crepi- 
tation upon  palpation.  In  rare  cases  this  condition  may  result  from  the 
rupture  of  dilated  peripheral  pulmonary  vesicles  in  emphysema. 

Succussion. — When  both  fluid  and  air  are  present  in  a  large  space  with 
rigid  walls,  as  in  pneumohydrothorax  or  pneumopyothorax,  a  distinct  vibra- 
tion or  impulse  may  be  felt  upon  shaking  the  patient  or  causing  him  to 
suddenly  twist  his  body.  This  phenomenon,  which  is  accompanied  by  a 
splashing  sound,  constitutes  the  sign  known  as  Hippocratic  succussion. 

The  arterial  pulse  is  studied  by  palpation.  This  subject  will  be  fully 
considered  in  a  later  section. 

Thrills. — The  palpable  vibrations  of  the  surface  transmitted  from 
the  interior  of  the  heart  or  arteries  are  known  as  thrills.  They  are  usually 
confined  to  limited  areas  and  may  be  easily  overlooked  unless  the  surface 
is  first  searched  with  the  palmar  surface  of  the  open  hand.  They  may 
then  be  studied  with  the  finger-tips.  They  can  frequently  be  felt  only 
upon  the  lightest  pressure,  wholly  disappearing  if  the  pressure  be  increased. 
The  sensation  has  been  compared  to  that  communicated  to  the  hand  by 
the  purring  cat — fremissement  cataire.  Thrills  are  usually  felt  during  a 
portion  of  the  cardiac  revolution  only — presystolic,  systolic,  post-systolic. 
They  may  disappear  when  the  heart  is  acting  feebly  and  become  manifest 
again  when,  with  general  improvement  in  the  condition  of  the  patient, 
the  heart  contracts  with  greater  power.  They  usually  correspond  in  the 
time  of  the  cardiac  cycle  with  audible  murmurs  or  bruits  and  are  signifi- 
cant of  the  same  lesions  and  produced  by  the  same  mechanism,  namely, 
fluid  veins,  the  vibrations  of  which  transmitted  through  tissues  to  the  sur- 
face are  realized  by  the  ear  as  murmurs,  by  the  touch  as  thrills.  In  other 
words  the  thrill  is  the  sensory  equivalent  of  the  murmur.  The  fact  tha£ 
very  coarse  thrills,  especially  the  presystolic  thrill,  sometimes  occur  when  no 
murmur  can  be  heard,  does  not  militate  against  the  foregoing  statement, 
since  regular  vibrations  may  be  palpable  though  not  frequent  enough 
to  produce  sound.  It  is  in  accordance  with  these  statements  that  thrills 
vary  in  the  rapidity  of  their  vibrations — fineness,  coarseness — and  that 
the  finer  thrills  correspond  to  the  higher  pitched  murmurs  and  the  reverse. 

A  thrill  at  the  base  of  the  heart  of  maximum  intensity  in  the  aortic 
area  is  common  in  aortic  stenosis. 

A  thrill,  of  coarse  quality,  limited  in  extent,  presystolic  in  time,  more 
marked  during  expiration,  and  most  distinctly  felt  in  the  fourth  or  fifth 
intercostal  space  inside  the  midclavicular  line — mitral  area — is  the  sign 
of  mitral  stenosis. 

A  systolic  thrill  in  the  same  area  is  sometimes  present  in  mitral 
incompetence  and  in  rare  instances  in  aortic  stenosis. 

A  thrill  often  accompanies  the  presystolic  murmur  of  aortic  incompe- 
tency— Flint's  murmur. 

A  thrill  diastolic  in  time  is  occasionally  felt  in  aortic  incompetency, 
but  is  not  very  common. 

Thrills  are  common  in  congenital  defects  of  the  heart. 

A  thrill  systolic  in  time  at  the  second  left  costal  cartilage  and  inter- 
space— pulmonary  area — is  occasionally  observed  in  exophthalmic  goitre; 


PHYSICAL  DIAGNOSIS:     PALPATION.  95 

very  rarely  it  is  a  sign  of  pulmonary  stenosis.     A  diastolic  thrill  in  this 
area  may  be  the  sign  of  a  rare  condition,  pulmonary  incompetency. 

A  thrill  over  the  lower  portion  of  the  sternum  and  at  its  right  border — 
tricuspid  area — sometimes  occurs  in  dilatation  of  the  right  ventricle  and 
tricuspid  incompetence. 

Systolic  thrills  when  beyond  the  limits  of  the  precordial  space  are 
more  likely  to  be  indicative  of  thoracic  aneurism  than  of  valvular  disease. 
They  are  oftenest  felt  to  the  right  of  the  sternal  border  and  above  the 
fourth  rib,  but  may  be  present  in  the  left  side  in  a  corresponding  region. 
They  are  more  common  in  aortic  dilatation  than  in  sacculated  aneurism. 

It  is  important  to  recognize  the  difference  between  a  thrill  and  the 
slight  shuddering  tremor  which  may  be  felt  in  the  merely  overacting 
heart,  as  in  palpitation  from  any  cause. 

Fremitus. — Fremere,  to  roar  or  murmur  as  a  crowd  or  mob;  techni- 
cally, palpable  vibration.  The  difference  between  a  thrill  and  fremitus 
is  much  more  readily  recognized  than  described.  It  is,  however,  an  essen- 
tial difference  and  depends  upon  the  difference  in  the  mechanism  by  which 
they  are  respectively  produced.  Fremitus  is  usually  much  coarser  than 
thrills,  the  vibrations  are  irregular  and  variable,  the  extent  is  far  wider, 
and  fremitus,  even  when  produced  by  the  movement  of  the  heart  as  in  the 
friction  fremitus  of  pericarditis,  does  not  constantly  conform  to  definite 
movements  in  the  cardiac  cycle.  Fremitus  is  a  tactile  phenomenon  com- 
municated to  the  surface  of  the  chest  by  the  act  of  phonation — vocal 
fremitus;  by  the  friction  of  roughened  surfaces  against  each  other — fric- 
tion fremitus;  or  by  the  respiratory  movement  of  exudates  of  varying 
consistency  within  the  bronchial  tubes — rhonchal  fremitus. 

Vocal  Fremitus. — This  physical  sign  is  of  great  value  in  the  diagnosis 
of  diseases  of  the  respiratory  organs.  It  is  frequently  spoken  of  as  tactile 
fremitus,  but  erroneously  so,  since  all  fremitus  is  tactile.  The  hand  is  laid 
upon  the  bared  chest  while  the  patient  counts  "one,  two,  three,"  or  repeats 
some  words,  as  "twenty-one"  or  "ninety-nine."  Under  normal  circum- 
stances the  fremitus  is  more  intense  in  men  than  in  women,  in  adults  than 
in  children,  and  in  persons  whose  voices  are  powerful  and  low-pitched  than 
in  those  whose  voices  are  feeble  and  shrill.  The  patient  should  be  asked 
to  repeat  the  same  phrase  as  the  examining  hand  passes  from  one  part 
of  his  chest  to  another,  and  to  let  his  speaking  be  loud,  low, and  slow,  always 
as  nearly  as  possible  in  the  same  tone.  This  method  of  physical  diagnosis 
is  without  value  in  persons  suffering  from  aphonia  or  in  those  so  feeble 
that  they  can  only  use  the  whispering  voice.  It  is  practicable  in  young 
infants  who  cry  during  the  examination. 

Vocal  Fremitus  ix  Health.  The  vibrations  of  the  vocal  cords 
in  phonation  are  transmitted  along  the  walls  of  the  trachea  and  bronchi 
and  the  column  of  air  which  they  contain  to  the  surface  of  the  chest,  which 
is  thus  set  into  vibration  from  within.  These  vibrations  vary  in  different 
regions  normally,  and  are  most  distinct  where  the  large  bronchial  tubes 
approach  the  chest  wall,  less  distinct  where  the  mass  of  intervening  vesicu- 
lar tissue  is  greatest,  and  feeble  or  absent  where  the  lung  tissue  dm-*  not 
come  into  contact  with  the  wall,  as  in  the  precordial  space.  Pathological 
conditions  which  increase  the  capacity  of  the  lung  to  conduct   vibrations, 


96  MEDICAL  DIAGNOSIS. 

as  consolidation,  intensify  the  vocal  fremitus;  those  which  separate  the 
lung  from  the  wall,  as  pleural  effusions,  diminish  or  abolish  it,  as  the  case 
may  be.  There  is  normally  considerable  difference  in  the  intensity  of  the 
vocal  fremitus  in  the  two  sides,  especially  in  the  upper  regions.  This 
inequality  is  to  be  constantly  borne  in  mind.  The  vibrations  are  more 
intense  on  the  right  than  on  the  left  side,  in  the  upper  (subclavicular) 
region  than  in  the  lower  (inframammary),  and  in  front  than  behind.  It  is 
feeble  over  the  scapulae,  and  usually  absent  or  very  feeble  in  that  portion 
of  the  precordial  space  which  corresponds  to  the  area  of  superficial  cardiac 
dulness.  A  thick  layer  of  subcutaneous  fat  impairs  the  value  of  this  physi- 
cal sign,  while  a  thin,  elastic  chest  wall  and  deep  voice  render  it  very  useful. 

Vocal  Fremitus  in  Disease  of  the  Respiratory  Organs. — The 
vibrations  are  intensified  by  conditions  which  cause  consolidation  of  the 
lung,  as  tuberculous  infiltration,  croupous  and  bronchopneumonia,  hypo- 
static congestion  and  atelectasis;  they  are  enfeebled  or  absent  altogether 
in  pathological  conditions  which  separate  the  periphery  of  the  lung  from 
contact  with  the  chest  wall,  such  as  pleural  effusion,  pneumothorax,  and 
cysts  or  tumors  in  the  pleural  cavity.  Pleural  thickening  is  usually  attended 
with  enfeeblement  of  the  vocal  fremitus  proportionate  to  its  degree,  and, 
as  a  much  thickened  pleura  gives  rise  to  impairment  of  resonance,  the 
differential  diagnosis  between  a  moderate  effusion  and  pleural  thickening 
may  be  attended  with  difficulty. 

Temporary  disappearance  of  vocal  fremitus  in  pneumonia  in  an  area 
corresponding  to  a  lobe  or  part  of  a  lobe  may  be  caused  by  the  plugging 
of  a  large  bronchus  with  a  mass  of  tenacious  mucus.  In  the  same  manner 
a  foreign  body  may  cause  localized  absence  of  this  sign.  In  infants  and 
less  frequently  in  adults  distinct  vocal  fremitus  is  occasionally  encountered 
upon  the  affected  side  in  large  effusions — a  very  puzzling  phenomenon. 
The  most  probable  explanation  of  this  anomaly  in  children  is  that  the 
intense  fremitus  caused  by  violent  crying  is  transmitted  along  the  elastic 
chest  walls  from  the  sound  to  the  affected  side  of  the  chest;  in  adults,  that 
tensely  stretched  strands  or  bands,  the  result  of  partial  adhesions  caused 
by  a  former  attack  of  fibrinous  pleurisy,  conduct  the  vibrations  from  the 
compressed  lung  to  the  wall  of  the  chest.  In  a  moderate  effusion  under 
favorable  circumstances  the  following  variations  may  be  recognized: 
normal  vocal  fremitus  over  the  apex,  enfeebled  fremitus  in  the  mammary 
region,  and  the  complete  absence  of  this  sign  at  the  base. 

If  the  limitations  of  its  usefulness  be  borne  in  mind,  vocal  fremitus 
is  a  sign  of  very  great  value,  but  it  may  mislead  the  unwary.  In  massive 
pericardial  effusion  it  is  of  great  service  in  the  differential  diagnosis 
between  that  condition  and  large  left-sided  pleural  effusion. 

Friction  Fremitus. — In  health  the  smooth  and  moist  pleural  and  peri- 
cardial surfaces  move  upon  each  other  without  appreciable  sound.  When 
these  surfaces  are  the  seat  of  a  fibrinous  exudate  they  cause  friction  sounds 
which  vary  with  the  arrangement  and  density  of  the  exudate  and  the 
energy  of  the  respiratory  or  cardiac  movements  as  the  case  may  be.  The 
vibrations  which  cause  the  sounds  are  transmitted  to  the  surface  and  con- 
stitute the  tactile  sign  known  as  friction  fremitus.  The  sensation  com- 
municated to  the  examining  finger  is  that  of  grating  or  rubbing  and  varies 


PHYSICAL  DIAGNOSIS:     PALPATION.  97 

from  the  finest  grazing  to  a  coarse  attrition.  It  corresponds  in  location 
and  extent  with  the  friction  sound  which  is  its  auditory  equivalent. 

Pleural  fremitus  is  common  in  the  infra-axillary  region  or  below 
the  nipple  and  is  not  transmitted  beyond  a  limited  area. 

Pericardial  fremitus,  which  is  the  sign  of  fibrinous  or  dry  peri- 
carditis, is  felt  in  the  precordial  space  over  the  right  ventricle.  It  does 
not  usually  correspond  in  time  accurately  with  the  systole  or  diastole, 
gives  the  impression  of  being  very  superficial  and  is  limited  to  a  circum- 
scribed area.  It  differs  from  the  thrills  felt  over  the  heart  in  the  tactile 
qualities  referred  to  in  a  preceding  paragraph. 

Pleural  fremitus  and  pericardial  friction  fremitus  disappear  as 
effusion  takes  place,  separating  the  roughened  surfaces,  and  as  adhesions 
develop,  by  which  the  surfaces  are  united. 

Rhonchal  Fremitus. — Coarse  bronchial  rales,  both  dry  and  moist, 
sometimes  communicate  irregular  vibrations  to  the  surface  of  the  chest 
readily  recognized  upon  palpation.  This  form  of  fremitus  is  common  in 
young  children  and  may  occur  in  thin-chested  adults.  It  differs  from  fric- 
tion fremitus  in  being  coarse  and  more  irregular  and  varying  in  intensity 
and  quality  with  the  rales  that  cause  it.    The  sign  is  of  little  diagnostic  value. 

Tracheal  tugging,  a  sign  first  described  by  Oliver,  is  of  great  value 
in  the  diagnosis  of  deep-seated  thoracic  aneurism.  "Place  the  patient  in 
the  erect  position  and  direct  him  to  close  his  mouth  and  elevate  his  chin 
to  almost  the  full  extent;  then  grasp  the  cricoid  cartilage  between  the 
finger  and  thumb  and  use  steady  and  gentle  upward  pressure  on  it.  when, 
if  dilatation  or  aneurism  exists,  the  pulsation  of  the  aorta  will  be  distinctly 
felt  transmitted  through  the  trachea  to  the  hand."  A  better  method  con- 
sists in  the  application  of  the  index  and  middle  fingers  of  the  same  hand 
on  the  sides  of  the  cricoid  cartilage,  or  the  physician  may  stand  behind 
the  patient,  who  is  seated,  and  place  the  forefingers  upon  the  sides  of  the 
cricoid,  with  gentle  upward  pressure.  The  downward  tug  may  be  readily 
recognized.  The  tug  is  due  to  the  fact  that  the  arch  of  the  aorta  passes 
over  the  loft  primary  bronchus  in  such  a  manner  that  when  the  aorta  is 
dilated  it  impinges  upon  the  bronchus  with  each  pulsation.  The  tension 
of  the  bronchus  is  communicated  through  the  trachea  to  the  larynx.  A 
downward  tug  felt  only  upon  inspiration  is  frequently  present  in  health 
and  has  no  diagnostic  value.  Pulsation  transmitted  from  the  vessels  of 
the  neck  to  the  cricoid  must  not  be  confounded  with  tracheal  tugging. 
The  movement  of  the  former  is  forward  and  backward;  of  the  latter  a 
distinct  downward  pull  with  release. 

Palpation  in  the  Examination  of  the  Abdomen. 

This  is  the  most  valuable  of  the  methods  of  physical  diagnosis  in 
diseases  of  the  organs  below  the  midriff.  The  patient  should  be  in  bed 
and  the  belly  should  be  bared  as  for  inspection.  The  hand  of  the  physi- 
cian should  be  warmed  and  applied  to  the  surface  with  gentle  pressure. 
One  or  both  hands  may  be  necessary.  Bimanual  palpation  may  be  from 
side  to  side,  the  wall  of  the  abdomen  being  deeply  folded  between  the 
hands,  or  any  accessible  organ  or  tumor  being  thus  investigated,  or  the 
7 


98  MEDICAL  DIAGNOSIS. 

bimanual  method  may  be  used  in  the  study  of  the  lateral  regions  of  the 
abdomen,  one  hand  being  placed  in  the  lumbar  region,  the  other  in  front. 
In  this  manner  the  border  of  the  liver  may  be  raised  up  against  the 
anterior  wall  or  a  floating  kidney  thrust  forward  for  examination,  or 
deep  fluctuation  elicited  in  paranephritic  or  appendiceal  abscess,  or  a 
hydronephrosis  studied,  or  the  contour  of  an  enlarged  spleen  or  carcinoma 
of  the  sigmoid  flexure  made  out.  When  the  object  of  the  examination  is 
to  localize  and  determine  the  degree  of  tenderness  it  is  better  to  study  the 
face  of  the  patient  than  to  depend  upon  his  statements  or  exclamations.  It 
is  also  important  to  distinguish  between  superficial  tenderness,  as  in  cutane- 
ous hyperesthesia  and  the  deep  tenderness  of  an  inflamed  or  tumid  organ. 
It  will  frequently  be  found  that  here  as  elsewhere,  in  neurotic  persons, 
more  vivid  expressions  of  pain  are  called  forth  by  a  light  touch  than  by 
firmer  pressure — a  fact  in  itself  of  great  diagnostic  importance. 

Excessive  abdominal  fat,  muscular  tension,  and  ticklishness  are  obsta- 
cles. The  first  often  nullifies  the  results  of  palpation;  the  others  may 
be  overcome.  Muscular  tension  due  to  apprehension,  the  excitement  of 
the  occasion,  or  other  nervous  causes  may  be  overcome  by  elevating  the 
head  upon  pillows  and  causing  the  patient  to  flex  his  thighs  and  knees; 
continuous  deep  or  rapid  breathing  is  also  useful.  Tact  and  address  on 
the  part  of  the  physician  and  suggestion  are  also  to  be  employed.  It  is 
frequently  necessary  to  examine  the  patient  under  general  anaesthesia 
before  expressing  a  final  opinion  as  to  the  nature  of  the  case,  and  finally, 
there  are  serious  cases  of  abdominal  disease  in  which  it  may  become  neces- 
sary to  perform  an  exploratory  operation  to  arrive  at  a  positive  diagnosis. 
Ticklishness  is  an  obstacle  of  minor  importance,  but  it  may  call  for  the 
exercise  of  much  patience  on  the  part  of  both  the  doctor  and  the  patient. 

It  often  becomes  necessary  to  turn  the  patient  from  side  to  side  or 
to  examine  him  in  the  knee-elbow  posture,  or  standing.  A  digital  exami- 
nation by  the  rectum  or  vagina  with  or  without  bimanual  manipulation 
is  frequently  required  in  'lesions  of  the  lower  portions  of  the  abdomen. 

The  regions  of  the  abdomen  must  be  in  turn  systematically  explored, 
the  natural  rings  and  accidental  sites  of  hernia  examined,  and  the  general 
outline,  contour,  and  condition  of  the  belly,  particularly  as  to  its  symmetry 
and  elasticity,  carefully  determined.  Large  knowledge  of  the  changes 
caused  by  abdominal  disease  and  wide  experience  are  required  in  this 
field  of  diagnosis.  Here  also  a  delicate  and  well-trained  touch — tactus 
eruditus — is  especially  serviceable. 

The  signs  obtained  by  inspection  are  confirmed  by  palpation.  Much 
knowledge  is  obtained  by  the  latter  method.  This  comprises  the  follow- 
ing subjects: 

The  Condition  of  the  Abdominal  Walls, 

General  and  Local  Fluctuation, 

Pulsation,  Thrill  and  Fremitus, 

The  Respiratory,  Postural,  and  Manipulative  Movements  of  Organs 
or  Tumors, 

Peristaltic  and  Fetal  Movements, 

The  Outline  and  Relations  of  Palpable  Tumors, 

Their  Density  and  Elasticity, 

The  Nature  of  the  Surface  of  Tumors. 


PHYSICAL  DIAGNOSIS:     PALPATION.  99 

The  Abdominal  Walls. — In  healthy  young  persons  the  belly  walls 
are  soft  and  elastic  but  neither  tense  nor  relaxed,  and  the  curvature  of 
the  abdomen  as  determined  by  inspection  and  palpation  is  symmetrical 
and  uniform. 

Abnormal  firmness  and  relaxation  are  attended  by  a  loss  of  healthy 
elasticity.  Local  firmness  may  be  caused  by  inflammatory  or  carcinoma- 
tous infiltration,  and  general  hardness  by  the  massive  enlargement  of  the 
liver,  spleen,  uterus,  an  ovary,  or  other  organ,  or  diffuse  malignant  deposits 
in  the  intestines  or  peritoneum.  Muscular  rigidity  is  characteristic  of  the 
early  stage  of  peritonitis.  It  may  be  localized,  as  in  the  right  lower  quad- 
rant in  appendicitis  or  enteric  fever,  or  general.  Local  rigidity  of  the 
bellies  of  the  recti  is  sometimes  observed  in  neurotic  persons  and  may  be 
mistaken  for  a  tumor,  as  a  thickened  or  carcinomatous  pylorus.  Local 
rigidity  with  meteorism  constitutes  phantom  tumor.  A  generalized  inelas- 
tic doughy  sensation  upon  palpation  is  often  observed  in  tuberculous 
peritonitis.  The  general  distention  of  ascites  is  associated  with  dulness 
save  in  the  upper  portions,  where  there  is  tympany,  and  with  fluctuation; 
that  of  meteorism  is  associated  with  tympany  everywhere,  including  the 
dependent  parts,  and  a  balloon-like  elasticity  quite  different  from  that  of 
the  normal  abdomen.  The  anasarcous  abdominal  wall  is  doughy,  inelastic, 
and  pits  upon  pressure;  dropsical  accumulations  are  seen  in  the  flank 
and  elsewhere  in  the  more  dependent  parts. 

Relaxation  follows  the  resorption  of  large  amounts  of  fat  and  repeated 
cbildbearing.  In  such  cases  the  belly  wall  is  often  pendulous  and  remark- 
ably puckered  and  thrown  into  folds  when  the  patient  lies  upon  her  back. 
Relaxation  also  follows  ascites  of  long  standing  and  the  removal  of  large 
tumors  and  is  usually  present  in  old  age  and  the  advanced  stages  of  wast- 
ing diseases.  In  women  who  have  borne  many  children  wide  separation 
of  the  recti  is  occasionally  seen,  the  connective  tissue  of  the  linea  alba 
being  enormously  stretched  and  thinned  and  the  gastric  and  intestinal 
peristalsis  plainly  seen  and  felt  over  a  large  area  in  the  middle  of  the 
abdomen.  In  such  cases  very  large  ventral  hernia  and  downward  displace- 
ment of  the  abdominal  viscera — Glenard's  disease — are  commonly  present. 

Local  tumors  of  the  abdominal  walls  are  abscess,  attended  by  local 
induration  and  central  softening;  cysts,  oval  or  circular  in  outline,  tense, 
elastic  and  fluctuating;  enlarged  lymph-nodes  in  the  inguinal  region: 
subcutaneous  carcinomatous  and  sarcomatous  tumors,  which  may  be  mov- 
able or  immovable,  and  arranged  in  irregular  masses  as  is  common  in  the 
former,  or  scattered  singly  over  a  wide  area  as  in  sarcoma;  and  hernia. 
The  last  appears  in  definite  locations,  as  the  inguinal  and  crural  rings,  the 
umbilicus,  in  the  linea  alba — ventral  hernia — and  in  the  sites  of  scars  after 
surgical  operations.  Upon  palpation  the  hernial  tumor  is  usually  soft, 
elastic  and  reducible;  omental  hernias  are  doughy  and  irregular  in  outline. 
The  hernia  which  cannot  be  returned  to  the  abdomen  by  manipulation 
is  irreducible,  that  which  is  tightly  constricted  and  is  therefore  likely  to 
become  or  has  already  become  sphacelated  is  strangulated. 

The  umbilicus  that  pouts  in  ascites  or  pregnancy  is  smooth,  stretched, 
and  somewhat  translucent.  In  umbilical  hernia  the  ring  is  usually  dis- 
tinctly felt;    when   omental   the  tumor  at  the  navel   is  often   large,   firm. 


100  MEDICAL  DIAGNOSIS. 

irregular  in  its  surface  and  irreducible  and  may  suggest  a  malignant  growth. 
The  umbilicus,  normally  somewhat  movable,  when  the  seat  of  secondary 
carcinoma,  usually  by  extension  from  the  liver,  becomes  fixed  and  is  indu- 
rated and  nodular.  Tuberculous  infiltration  of  the  tissues  around  the 
navel  has  been  observed  in  tuberculosis  of  the  peritoneum.  A  deeply 
seated,  painful  swelling  of  the  navel  is  usually  an  abscess. 

Fluctuation. — This  sign  is  elicited  by  combined  bimanual  percussion 
and  palpation,  those  methods  being  employed  at  the  limits  of  the  area 
examined,  as  for  example  at  the  right  and  left  lateral  regions  of  the  abdo- 
men in  suspected  ascites  and  at  the  opposite  borders  of  circumscribed 
collections  of  fluid  as  in  pancreatic  or  other  cysts.  To  elicit  general  fluc- 
tuation the  palpating  left  hand  or  finger-tips  are  lightly  laid  upon  the  sur- 
face of  the  right  side  of  the  patient's  abdomen,  while  with  the  fingers  of 
his  right  hand  the  examiner  percusses  or  taps  somewhat  sharply  upon 
the  left  side  of  the  abdomen.  If  there  be  ascites  a  transmitted  wave  cor- 
responding to  each  tap  is  felt  upon  the  opposite  side.  This  wave  is  also 
in  many  cases  visible.  Very  light  percussion  may  bring  out  this  physical 
sign  when  the  wall  of  the  abdomen  is  thin.  The  thin  ulnar  border  of  the 
hand  of  an  assistant  must  be  rather  firmly  pressed  against  the  abdomen 
in  the  middle  line  to  arrest  the  undulatory  transverse  movement  of  the 
wall,  which  very  often  simulates  the  fluctuation  of  peritoneal  effusion. 
This  sign  does  not  arise  unless  the  fluid  is  freely  movable  and  sufficient 
in  amount  to  rise  above  the  pelvis — two  or  more  litres. 

The  method  of  determining  fluctuation  in  circumscribed  collections 
of  fluid,  as  pancreatic  or  other  cysts  within  the  abdomen,  circumscribed 
effusions,  dropsy  or  empyema  of  the  gall-bladder,  etc.,  is  somewhat  differ- 
ent in  technic  and  available  only  in  patients  whose  belly  walls  are  com- 
paratively thin.  The  tips  of  the  palpating  fingers  are  lightly  placed  in 
contact  with  the  surface  at  one  border  of  the  area  under  examination  while 
the  opposite  border  is  sharply  but  lightly  flicked  with  the  nail — dorsal 
surface  of  the  tip  of  the  middle  or  ring  finger  suddenly  disengaged  from 
contact  with  the  palmar  surface  of  the  thumb,  as  one  flicks  a  crumb.  By 
this  method  not  only  can  fluctuation  of  limited  extent  be  determined  but 
also  the  limits  of  the  area  in  which  it  is  present  defined. 

Pulsation,  Thrill  and  Fremitus. — Pulsation. — In  thin  persons  the 
normal  pulsation  of  the  aorta  may  be  felt  upon  deep  palpation  in  the  middle 
line  about  the  level  of  the  umbilicus.  Abnormal  pulsation  of  the  abdomi- 
nal aorta  is  of  two  kinds,  the  so-called  dynamic  pulsation  seen  in  neurotic 
persons,  not  expansile  and  not  associated  with  tumor  or  other  signs  of 
dilatation  of  the  vessel,  and  the  expansile  pulsation  of  abdominal  aneurism, 
in  which  a  tumor  that  can  be  grasped  between  the  hands  and  is  the  seat 
of  distinct  expansile  pulsation  may  be  present  together  with  other  signs 
of  aneurism.  The  differential  diagnosis  between  these  two  forms  of  pul- 
sation should  not  be  a  matter  of  doubt.  Pulsation  is  sometimes  trans- 
mitted from  the  aorta  to  a  tumor  overlying  it  in  such  a  manner  as  to 
simulate  aneurism,  especially  as  the  pressure  of  the  tumor  may  cause 
both  bruit  and  thrill.  The  fact  that  the  pulsation  is  not  expansile  and  the 
palpation  of  the  tumor  in  the  knee-elbow  posture,  when  the  movement  of 
the  aorta  is  no  longer  communicated  to  it,  serve  to  render  the  differential 


PHYSICAL  DIAGNOSIS:     PALPATION.  101 

diagnosis  between  such  a  tumor  and  aneurism  a  matter  of  comparative 
ease.  Dynamic  pulsation  of  the  aorta  is  felt  in  the  course  of  the  vessel 
in  the  middle  line  and  slightly  to  the  left  of  it;  that  of  aneurism  is  usually 
more  extended  transversely  and  may  be  felt  some  distance  to  the  left, 
even  reaching  almost  as  far  as  the  iliac  crest,  as  I  saw  in  a  case  verified 
by  autopsy. 

The  liver  pulsation  due  to  tricuspid  incompetency — hepatic  venous 
pulse — may  frequently  be  recognized  upon  palpation,  especially  bimanual 
palpation,  when  it  is  not  visible  upon  inspection,  and  by  the  former  method 
the  difference  between  the  expansive  movement  of  a  pulsating  liver  and 
the  jogging  due  to  the  communicated  movement  of  the  heart  may  be 
appreciated. 

Thrill. — This  sign  is  sometimes  met  with  in  abdominal  aneurism  and 
tumors  pressing  upon  the  aorta.     It  has  little  diagnostic  significance. 

Fremitus  is  the  sign  of  echinococcus  cysts — hydatid  fremitus  or  thrill. 
The  tumor  is  soft,  elastic,  fluctuating,  and  in  the  majority  of  cases  the  seat 
of  a  peculiar  vibration  or  fremitus,  which  may  be  felt  by  palpation  with 
two  or  three  fingers  of  the  same  hand  or  by  placing  three  finger-tips  widely 
separated  upon  the  surface  and  lightly  percussing  the  middle  finger.  Gall- 
stone fremitus  is  sometimes  elicited  upon  palpation  of  the  gall-bladder 
distended  with  a  large  number  of  calculi.  It  is  a  comparatively  rare  but 
very  important  sign. 

Movements  of  Abdominal  Organs  or  Tumors. — The  movements  oi 
intra-abdominal  organs  and  tumors  constitute  physical  signs  of  great 
value  in  diagnosis.    They  are  respiratory ,  postural,  and  manipulative. 

Respiratory  movements  are  communicated  to  the  organs  in  close  rela- 
tion to  the  diaphragm,  especially  the  liver,  spleen,  and  to  a  less  extent  the 
kidneys.  Tumors  of  the  stomach  are  usually  but  little  influenced  by  the 
movements  of  the  diaphragm.  Conditions  which  hinder  the  respiratory 
movements  of  the  diaphragm,  such  as  pleurisy,  emphysema,  massive  en- 
largement of  the  liver  or  spleen,  advanced  pregnancy,  meteorism  and  ascites, 
restrict  or  wholly  arrest  the  respiratory  movements  of  abdominal  viscera. 
The  anatomical  relations  of  the  pancreas  and  retroperitoneal  glands  are  such 
that  they  are  not  influenced  by  the  movements  of  respiration.  Very  large 
cysts  of  the  pancreas  may  show  slight  movement  on  deep  breathing. 

Intra-abdominal  new  growths  which  are  influenced  by  respiratory 
movements  originate  in  the  upper  portion  of  the  cavity;  those  which  manifest 
no  respiratory  movement  upon  careful  palpation  commonly  but  not  always 
develop  from  the  pelvic  organs  or  from  structures  directly  connected  with 
tin'  spinal  column  behind  the  peritoneum— pancreas,  retroperitoneal  lym- 
phatic  glands,  aneurism. 

Postural  Movements.— Free  fluid  in  the  cavity  tends  to  gravitate  to 
the   most   dependent   space,  while    the    air-containing    intestines    float    upon 

the  surface  of  the  fluid.  Small  effusions  may  cause  dulness  in  (he  umbilical 
region  when  the  patient  assumes  the  knee-elbow  position.  Floating  viscera, 
kidneys,  spleen,  and  in  very  rare  instances  the  liver,  are  recognized  upon 
palpation  by  their  size,  shape,  and  general  relationships.  A  liver  dislocated 
has  little  range  of  movement,  but  the  kidney  and  spleen  may  be  found  in 
distant  regions  of  the  abdominal   cavity,  even  at  the  brim   of   the    pelvis. 


102  MEDICAL  DIAGNOSIS. 

The  Technic  of  Palpation  of  the  Kidney. — The  recognition  of 
a  displaced  kidney  is  not  attended  with  difficulty.  Palpation  should  be 
bimanual,  one  hand  pressing  upward  from  the  lumbar  region  while  the 
other  is  gently  moved  over  the  anterior  surface  of  the  abdomen,  which 
should  be  as  relaxed  as  possible.  The  tumor  is  oval,  smooth,  firm,  and  has 
the  oblong  shape  of  the  kidney.  It  is  sometimes  possible  to  recognize  the 
hilum  and  to  feel  the  pulsating  renal  artery.  The  tumor  is  usually  sensi- 
tive to  firm  pressure  and  freely  movable.  In  the  knee-elbow  posture  it 
advances  towards  the  wall  of  the  abdomen,  while  it  sinks  backward  and 
may  be  pressed  into  its  normal  position  when  the  patient  assumes  the 
dorsal  decubitus.  In  the  lateral  and  erect  postures,  it  sinks  to  the  lowest 
point  of  its  range  of  movement.  Except  in  the  case  of  a  much  elongated 
mesonephron,  it  moves  also  with  the  movements  of  respiration.  Wan- 
dering kidney  is  more  common  in  women,  in  multipara?,  upon  the  right 
than  the  left  side  and  is  occasionally  bilateral. 

The  Technic  of  Palpation  of  the  Spleen.— The  patient  should 
be  placed  in  a  position  midway  between  right  lateral  and  dorsal,  with 
his  left  hand  upon  his  head.  The  thighs  should  be  flexed  in  order  to  relax 
as  far  as  possible  the  abdominal  wall.  The  head  should  be  slightly 
retracted  and  the  patient  directed  to  breathe  deeply  and  slowly.  The 
physician,  standing  at  the  patient's  right,  exerts  with  his  left  hand  firm 
pressure  upon  the  infra-axillary  region  downwards  and  forwards  while,  with 
his  right  hand,  he  presses  the  soft  belly  wall  below  the  arch  of  the  ribs 
upwards  and  inwards  to  determine  whether  or  not  the  lower  border  of  the 
spleen  can  be  felt  and  in  particular  at  the  end  of  deep  inspiration.  Too 
much  force  must  not  be  employed  lest  a  greatly  softened  spleen,  as  in  enteric 
fever,  might  be  ruptured.  The  data  yielded  by  percussion  in  the  examination 
of  the  spleen  are  rendered  uncertain  by  gastrectasis,  meteorism,  pleural 
effusion,  and  fecal  accumulations  in  the  colon  and  new  growths  in  the  splenic 
region.  The  results  of  palpation  in  moderate  enlargement  are  much  more 
satisfactory  and  reliable. 

The  diagnosis  of  massive  enlargement  of  the  spleen  is  usually  a  matter 
of  ease  and  certainty.  The  contour  of  the  tumor,  upon  which  may  be  dis- 
tinctly felt  a  sharply  rounded  inner  border,  often  notched  opposite  the 
hilum,  its  firmness,  its  slight  movement  upon  deep  breathing,  and  the  smooth- 
ness of  the  surface  are  of  diagnostic  importance. 

Wandering  spleen  is  not  often  difficult  of  recognition.  The  displaced 
organ  is  readily  palpable  below  the  left  hypochondrium,  less  often  in  the 
umbilical  or  left  iliac  region,  and  very  rarely  at  the  brim  of  the  pelvis,  as 
a  smooth  oval  tumor  of  the  outline  of  the  spleen,  notched  and  freely  mov- 
able upon  change  of  posture  and  by  manipulation.  If  the  organ  occupies  a 
position  to  which  the  movements  of  the  diaphragm  do  not  extend,  it  does 
not  move  even  upon  the  deepest  respiration. 

Movements  upon  Manipulation. — All  abnormal  organs  and  tumors 
that  change  their  position  in  response  to  changes  in  posture  are  movable 
upon  manipulation  or  palpation.  The  list  comprises  floating  liver,  spleen, 
and  kidney;  in  the  absence  of  adhesions,  tumors  of  the  pylorus  and  less 
frequently  of  other  parts  of  the  stomach,  as  the  greater  curvature,  new 
growths  in  the  intestines,  excepting  the  ascending  and  descending  colon; 


PHYSICAL  DIAGNOSIS:     PALPATION.  103 

fecal  accumulations,  gall-stones  and  enteroliths;  mesenteric  and  omental 
tumors.  The  range  of  movement  is  limited  in  tumors  of  the  gall-bladder 
and  pancreatic  cyst,  in  the  upper  regions  of  the  abdomen;  very  limited 
in  tumors  of  the  ascending  and  descending  colon  laterally  and  enlarge- 
ments of  the  uterus  and  ovaries  in  the  lower  segment.  All  malignant  and 
some  benign  tumors  tend  to  contract  adhesions  which  interfere  with  move- 
ment. The  following  are  immovable,  small  tumors  of  the  pancreas,  retro- 
peritoneal growths,  peri-appendiceal  infiltration,  adhesions  and  abscess, 
abdominal  aneurism  and  abscesses. 

Peristaltic  and  Fetal  Movements.  —  The  peristaltic  movements 
may  sometimes  be  felt,  as  they  may  be  seen,  in  thin  individuals  in  health 
and  when  in  obstruction  of  the  bowel  they  become  excessive.  In  chronic, 
slowly  developing  stenosis  of  the  gut  the  musculature  of  the  intestines 
undergoes  hypertrophy  and  the  peristalsis  becomes  proportionately  more 
powerful.  Antiperistaltic  or  reverse  waves  may  sometimes  be  felt.  Pal- 
pable coarse  intestinal  movements  with  the  formation  of  knots  accom- 
panied by  borborygmi  may  be  present  in  colic  and  in  hysteria.  The  gastric 
and  intestinal  movements  are  very  plainly  felt  and  seen  in  cases  of  wide 
separation  of  the  recti  in  women  who  have  borne  many  children. 

The  movements  of  the  foetus  may  be  often  plainly  felt  upon  palpation, 
and  in  advanced  pregnancy  the  position  of  the  fcetus  may  be  recognized 
by  this  method  of  examination.  All  these  movements  may  be  rendered 
more  active  by  manipulation  and  the  sudden  application  of  cold. 

Outline. — By  palpation  we  determine  whether  an  intra-abdominal  mass 
is  round,  oval,  or  irregular  in  outline;  whether  it  is  rough,  nodular,  or  smooth; 
whether  it  resembles  a  viscus  as  the  kidney  or  spleen  in  shape  and  has  char- 
acteristic anatomical  features,  as  the  hilum  or  a  pulsating  artery.  We  ascer- 
tain its  apparent  point  of  origin,  as  in  the  epigastrium,  the  lateral  regions  of 
the  abdomen,  or  the  pelvis,  and  whether  or  not  it  has  direct  attachments  or 
relations  with  another  organ,  such  as  may  be  made  out  between  an  enlarged 
gall-bladder  and  the  liver,  carcinoma  of  the  pylorus  and  the  stomach,  or  a 
large  cyst  in  the  left  hypochondrium  and  the  pancreas. 

Density  and  Elasticity. — The  signs  relating  to  the  consistency  of  an 
intra-abdominal  mass  can  be  ascertained  by  palpation  alone.  We  thus 
determine  whether  it  is  fluctuating  as  in  abscess  or  cyst;  soft  as  in  rapidly 
developing  new  growths  and  aneurism;  moderately  firm  as  in  organs  the 
scut  of  congestion  and  hypertrophy,  or  dense  as  in  slowly  developing  car- 
cinoma or  interstitial  overgrowths.  In  fecal  accumulations  the  tumor  is 
sometimes  hard  and  firm,  sometimes  soft  and  doughy  and  can  be  indented 
by  the  finger. 

Surface. — Palpation  enables  us  to  study  the  surfaces  of  organs  and 
tumors.  The  smooth  surface  of  an  amyloid  or  fatty  liver,  the  coarse  granular 
surface  of  the  liver  in  atrophic  cirrhosis,  the  nodular  liver  with  its  rounded 
isolated  eminences  at  the  summit  of  which  slight  depressions  may  be  felt — 
Fane's  tubercles — in  cancer,  are  examples  of  surface  changes  of  diagnostic 
importance.  The  smooth  surface  of  the  distended  gall-bladder  stands  in 
Strong  contrast  with  the  irregular  outline  of  carcinoma  of  the  pylorus;  the 
irregular  multilocular  echinococcus  of  the  liver  can  hardly  be  differentiated  from 
hepatic  cancer,  but  is  wholly  unlike  the  smooth,  elastic,  and  vibrating  single 


104  MEDICAL  DIAGNOSIS. 

hydatid  cyst.  The  smooth,  elastic,  and  fluctuating  cyst  in  hydronephrosis 
differs  altogether  from  the  firm,  nodular  and  irregularly  shaped  mass  in 
carcinoma  of  the  kidney;  and  the  smooth,  ovoid,  nearly  centrally  placed 
tumor  of  early  pregnancy  is  wholly  unlike  the  tumor  formed  by  irregular, 
coarsely  nodular  subperitoneal  uterine  myomata. 

MENSURATION. 

Instruments  of  Precision — Graphic  Methods. 

The  use  of  instruments  of  precision  is  of  great  importance  in  physical 
diagnosis.  Such  appliances  vary  from  a  simple  graduated  tape  to  the 
most  intricate  and  delicate  haemodynamometer  or  polygraph.  The  writer 
holds  the  opinion  that  simplicity  both  of  method  and  of  instruments 
yields  the  most  satisfactory  results  at  the  bedside,  and  that  intricate  and 
costly  mechanical  devices  which  require  great  technical  skill  and  con- 
sume much  time  are  better  suited  to  scientific  research  than  to  every-day 
clinical  work. 

Measurement  of  the  chest — thoracometry — may  be  conveniently  made 
by  a  steel  tape  graduated  upon  one  side  in  centimeters,  on  the  other  in 
inches ;  the  diameters  are  taken  by  calipers  made  for  the  purpose. 

The  circumference  and  semicircumferences  are  taken  at  the  level  of 
the  nipples  or  the  fourth  eostosternal  articulation  in  quiet  breathing,  in  full 
held  inspiration  and  on  full  expiration.  Care  must  be  taken  that  the  tape 
is  horizontal.  The  normal  chest  is  nearly  but  not  quite  symmetrical,  the 
right  semicircumference  being  in  the  majority  of  individuals  slightly  larger 
than  the  left — an  average  difference  of  about  half  an  inch.  It  is  well  to 
make  a  mark  with  a  dermatographic  pencil  in  the  median  line  in  front 
and  over  a  vertebral  spine  at  the  same  level  and  measure  the  semicircum- 
ference from  point  to  point  on  each  side  for  comparison.  Two  tapes  attached 
to  a  little  wooden  saddle  which  fits  over  a  vertebra  are  useful  to  determine 
the  semicircumference  on  quiet  breathing  and  the  differences  on  forced 
respiration.  The  average  circumference  in  men  is  34.3  inches  (87  cm.)  ; 
in  women  29.5  inches — (75  cm.).  The  difference  in  forced  expiration  and 
full  held  inspiration  varies  in  normal  individuals  between  1.5  (4  cm.)  and 
5  inches  (12.5  cm.). 

The  main  diameters  of  the  chest  at  the  same  level  as  taken  by  compass 
calipers  with  curved  arms  or  slide  calipers  are :  anteroposterior  (the  depth 
of  the  chest)  average  in  repose  in  men  7.5  inches  (19  cm.)  ;  in  women  6.9 
inches  (17  cm.)  ;  bilateral  or  transverse  (the  breadth  of  the  chest),  average 
in  men  9.9  inches  (25  cm.). 

Spirometry. —  By  this  means  we  ascertain  the  volume  of  the  tidal  air. 
The  instrument  used  is  the  spirometer.  Various  forms  are  in  use,  but  the 
results  are  far  from  satisfactory.  The  instruments  are  cumbersome  and 
require  a  certain  amount  of  training  to  obtain  constant  results.  The  sex,  age, 
weight  and  height  must  be  taken  into  account.  Thus  for  every  inch  above 
five  feet,  eight  cubic  inches  are  to  be  added  to  the  normal  standard,  which 
for  five  feet  is  17  cubic  inches.  The  estimated  average  lung  capacity  for 
height  in  males  between  sixteen  and  forty  years  of  age  is,  according  to  Otis, 


PHYSICAL  DIAGNOSIS:    MENSURATION. 
CYRTOMETRIC  TRACINGS. 


105 


Fig.  48g. — Outline  of  normal  chest. 


lii..  4s6. — Outline  of  emphysematous  chest. 


Fig.  49a. — Outline  of  chest  showing  "funnel  shaped"  Fig.  49b. — Outline  of  phthisical  sheet 

deformity. 


In;.  60a. — Outline  of  the  chest  in  >pin:il  curvature. 


Fici.  606. — Outline  of  the  eheal  in  rickets. 


106  MEDICAL  DIAGNOSIS. 

twenty-three  cubic  centimeters  for  every  centimeter  of  height ;  in  females  at 
nineteen  years  of  age,  it  is  fifteen  cubic  centimeters  for  each  centimeter  of 
height. 

Waldenburg's  pneumatometer  is  an  apparatus  designed  to  measure  the 
respiratory  energy.  Normally  the  power  exerted  in  expiration  is  greater 
than  in  inspiration  by  from  twenty  to  thirty  millimeters  of  mercury.  In 
emphysema  and  asthma  the  expiratory  pressure  is  greatly  diminished,  while 
in  certain  forms  of  phthisis  the  inspiratory  power  is  much  lessened. 

Crytometry. —  The  determination  of  the  outline  of  a  cross-section  of 
the  chest  may  be  made  with  an  instrument  called  a  cyrtometer — measure 
of  the  curve.  This  procedure  is  of  no  great  use  in  ordinary  clinical  work 
but  very  suggestive  and  important  in  teaching.  Elaborate  and  costly 
instruments  are  not  necessary  for  this  purpose.  The  best  device  consists 
in  a  little  metal  saddle  made  to  fit  the  spine,  to  each  side  of  which  is  hinged 
a  strip  of  leaden  ribbon  half  an  inch  in  width  and  thick  enough  to  be  easily 
bent  so  as  to  conform  to  the  surface  of  the  chest,  yet  retain  its  form  when 
removed.  The  saddle  is  set  upon  the  spine  at  the  level  selected,  the  leaden 
band  is*  carefully  adjusted  to  the  surface  on  each  side  and  made  to  meet 
at  the  median  line  in  front.  It  is  then  released,  opened  at  the  hinges, 
removed  from  the  chest  and  then  laid  upon  a  sheet  of  paper,  the  ends 
being  brought  together  at  the  point  of  meeting  in  the  median  line.  The 
outline  is  controlled  by  the  fixation  of  the  main  diameters  by  means  of 
the  calipers.  A  soft  pencil  is  then  used  to  make  the  tracing  on  the  inside 
of  the  cyrtometer.  The  various  deformities  of  the  chest  described  under 
inspection  may  be  thus  depicted. 

Circumferential  measurements  of  the  abdomen  at  the  level  of  the 
umbilicus  and  vertical  measurements  from  the  ensiform  cartilage  are 
useful,  especially  for  purposes  of  comparison  in  ascites  and  enlargements 
from  tumor  or  other  conditions.  They  are  best  made  with  the  ordinary 
graduated  tape.  Measurements  from  various  fixed  points  upon  the  surface 
of  the  thorax  or  abdomen  are  necessary  for  purposes  of  record. 

Methods  of  Recording  the  Circulatory  Movements.1 

The  Sphygmograph. — The  first  instrument  introduced  into  clinical  medi- 
cine for  the  purpose  of  recording  circulatory  movements  was  the  sphygmo- 
graph. By  its  use  a  single  record,  usually  of  the  pulsation  in  the  radial 
artery,  is  obtained.  After  many  years  of  careful  work  with  this  instrument 
it  has  now  been  practically  discarded.  It  has  fallen  into  disrepute  because  it 
fails  to  yield  the  knowledge  which  is  to-day  considered  essential  for  the  proper 
understanding  of  many  disturbances  of  the  circulation.  In  fact,  except  for 
the  sake  of  a  permanent  objective  record,  little  is  gained  which  can  not  be 
foretold  by  the  well-trained  palpating  finger.  The  form  of  the  curves  ob- 
tained from  the  pulsation  in  the  artery  is  so  liable  to  alteration  by  the 
improper  adjustment  of  the  instrument,  or  by  the  anatomical  conditions, 
that  conclusions  drawn  from  the  record  are  uncertain.  The  sphygmograph 
may,  therefore,  be  considered  of  but  meagre  clinical  value  and  the  instru- 
ment will  not  be  further  discussed. 

i  Contributed  by  G.  Canby  Robinson,  M.A.,  as  collaborator. 


PHYSICAL  DIAGNOSIS:     MENSURATION. 


107 


The  Polygraph. — An  important  contribution  to  the  study  of  circulatory 
disturbances  was  made  when  James  Mackenzie  introduced  the  polygraph  into 
clinical  medicine.  This  instrument  allows  two  or  more  simultaneous  graphic 
records  of  circulatory  movements  to  be  made.  By  recording  the  pulsations  of 
the  jugular  vein  and  of  the  radial  artery-  at  the  same  time,  the  movements  of 
the  auricles  and  of  the  ventricles  can  be  studied.     The  study  of  the  move- 


Fig.  51. — Jaquet  portable  polygraph. 

ments  of  the  two  chambers  of  the  heart  has  proved  of  great  value  in  allow- 
ing the  various  types  of  cardiac  irregularities  to  be  differentiated. 

Instruments  have  been  devised  which  are  readily  portable  and  applicable 
at  the  bedside  or  in  the  office. 

Two  forms  of  instruments  have  come  into  general  use  for  this  purpose: 


Fi<i.  52.— The  Mackenzie  ink  polygraph. 

the  Jaquet  polygraph,  which  records  the  pulsations  of  the  radial  artery  and 
the  jugular  vein  an  smoked  paper  I  Fig.  51  i,and  the  Mackenzie  ink  polygraph 
(Fig.  52).  Each  instrument  Lb  provided  with  a  time-marker,  marking  off 
fifths  of  seconds  so  that  intervals  of  distance  on  the  records  can  1"'  con- 
verted into  intervals  of  lime.  The  latter  instrument  is  to  be  recommended 
for  clinical  purposes  when  used  away  from  a  laboratory,  as  smoked  paper 
presents  inconveniences.  The  Mackenzie  instrument  also  allows  prolonged 
records  to  be  made  while  the  Jaquet  does  not.    An  ordinary  kymograph  as 


108 


MEDICAL  DIAGNOSIS. 


used  in  physiological  laboratories,  set  upon  a  table  on  wheels,  is  service- 
able for  hospital  use. 

The  study  of  the  venous  pulse  record  has  laid  the  foundation  for  a 
clear  understanding  of  the  disturbances  of  the  cardiac  mechanism.  The 
normal  pulsations  in  the  jugular  vein  yield  a  record  consisting  of  three 
main  waves  (Fig.  53).  These  waves  have  been  designated  "A,"  "C,"  and 
"  V  "  waves,  because  they  are  known  as  the  auricular,  the  carotid  and  the 
ventricular  waves.  They  bear  a  constant  relation  to  one  another  and  mark 
the  definite  activities  in  the  cardiac  cycle.  The  "  A  "  wave  is  caused  by  an 
increased  pressure  in  the  jugular  vein  resulting  from  the  contraction  of 
the  right  auricle,  which,  while  forcing  the  blood  into  the  ventricle,  also  stops 
the  onflow  of  venous  blood  and  causes  as  well  back  pressure  in  the  great 
veins.  The  "  C  "  wave  accompanies  ventricular  contraction,  and  at  least 
in  part  is  the  result  of  the  upward  bulging  of  the  tricuspid  valves  and  the 
base  of  the  auricles.    The  wave  is  often  augmented  by  the  pulsation  in  the 


Ju^u.\<^v  Pulse. 
3»<cty;fci  Pulse 


1/sSec 


Fig.  53.— Xormal  record.      Polvgraphic   tracing,    the  jugular  pulse  above  and  the  brachial  pulse  below. 
Normal  relation  of  A  and  C  waves  shown. 

carotid  artery  which  lies  under  the  vein.  The  "  V  "  wave  occurs  during 
the  latter  part  of  ventricular  systole,  the  crest  of  the  wave  marking 
the  completion  of  systole  and  the  onset  of  diastole.  The  wave  subsides 
when  the  tricuspid  valves  open  and  allow  once  more  free  passage  of  venous 
blood  from  the  veins  through  the  right  auricle  into  the  ventricle.  Other 
waves  have  been  described,  but  as  they  have  but  little  bearing  on  clinical 
diagnosis  they  will  not  be  discussed. 

The  interpretation  of  the  venous  pulse  tracing  is  only  possible  with  cer- 
tainty when  it  is  accomplished  by  a  tracing  from  the  radial  or  from  some 
other  artery.  By  comparison  of  the  radial  arterial  tracing  with  the  venous 
tracing,  the  "  C  "  wave  of  the  latter  can  be  identified,  as  with  each  heart- 
beat it  precedes  the  onset  of  the  radial  tracing  by  about  one-tenth  of  a 
second,  or  half  of  one  interval  marked  by  the  time-marker  on  the  record. 
When  the  "  C  "  wave  of  the  venous  tracing  is  identified,  it  will  be  found 
to  follow  the  "  A  "  wave  in  the  normal  record  by  about  one-fifth  of  a  second. 
The  measurement  is  made  from  the  onset  or  "foot-point"  of  each  wave.  It 
is  the  relation  of  the  "  A  "  and  "  C  "  waves  which  is  of  greatest  value  in 


PHYSICAL  DIAGNOSIS:    MENSURATION.  109 

the  interpretation  of  the  cardiac  action,  as  their  normal  relation  is  only  dis- 
turbed when  there  is  a  lack  of  proper  coordination  of  the  auricles  and 
ventricles  of  the  heart.  As  nearly  all  forms  of  cardiac  arrhythmia  are 
accompanied  by  a  lack  of  proper  coordination  of  the  auricles  and  ventricles, 
the  question  of  this  coordination  is  an  important  one.  The  polygraph  will 
usually  show  whether  there  is  a  normal  relation  or  not  between  the  activities 
of  the  auricles  and  ventricles,  and  will  indicate  the  various  types  of  cardiac 
irregularities  from  one  another.  This  differentiation  is  essential  for  the 
diagnosis,  prognosis,  and  treatment  of  cardiac  disorders  accompanied  by 
irregularities  of  the  heart. 

The  analysis  of  polygraphia  records  obtained  from  cases  in  which 
various  disturbances  of  the  heart-beat  are  present  is  not  difficult  when  the 
normal  mechanism  of  the  heart  is  kept  in  mind.  It  must  be  remembered 
that  the  impulse  which  sends  the  heart  into  contraction  starts  in  the  sinus 
node  situated  in  the  upper  portion  of  the  right  auricle  and  spreads  rapidly 
throughout  the  auricles,  setting  up  a  simultaneous  contraction  of  both 
auricles.  The  impulse  then  passes  from  them  through  the  auriculo-ventricu- 
lar  bundle  (bundle  of  His)  and  reaches  the  ventricles  after  a  definite  interval 
of  time.  The  impulse  is  then  carried  rapidly  through  the  ventricular  con- 
ducting system,  and  sets  the  two  ventricles  into  simultaneous  contraction. 
Any  disturbance  of  rate  of  impulse  conduction  or  of  the  normal  sequence 
of  the  cardiac  activity  will  be  manifested  by  a  disturbance  in  the  coordina- 
tion of  the  contractions  of  the  auricles  and  ventricles,  and  will  show  itself 
in  the  record  obtained  by  the  polygraph. 

The  various  disturbances  of  the  heart-beat  in  which  the  use  of  the 
polygraph  have  been  of  especial  value  can  be  classified  as  follows: 

Sinus  arrhythmia, 

Extrasystoles,  or  premature  beats  of  the  auricles, 

Auricular  flutter, 

Auricular  fibrillation, 

Disturbances  of  conduction, 
Delayed  conduction, 
Partial  heart-block, 
Complete  heart-block, 

Extrasystoles,  or  premature  beats  of  the  ventricles. 
Each  of  these  types  of  disturbed  cardiac  mechanism  can  be  distinguished 
by  means  of  polygraphia  tracings. 

Sinus  arrhythmia  is  caused  by  the  irregular  onset  of  the  cardiac  impulse, 
and  shows  itself  in  the  venous  pulse  tracing  by  the  occurrence  at  irregular 
time  intervals  of  the  group  of  waves  which  are  seen  with  each  normal 
cardiac  contraction.  There  is  in  this  condition  no  disturbance  of  the  normal 
relations  of  auricles  and  ventricles,  and  therefore  the  "A"  and  "C' 
waves  have  throughout  the  norma]  relation  to  one  another. 

Extrasystoles  or  premature  beats  of  the  auricles  are  indicated  in  the 
venous  tracing  by  the  occasional  occurrence  of  premature  "  A  "  waves, 
which  are  generally  followed  by  "  C  "  waves  bearing  the  normal  relation  to 
them.  This  type  of  cardiac  irregularity  results  from  the  premature  con- 
traction of  the  auricles,  set  up  by  an  impulse  generated  somewhere  in  the 


110 


MEDICAL  DIAGNOSIS. 


auricles  themselves,  before  the  rhythmical  impulse  from  the  sinus  node 
reaches  them.  The  impulse  of  this  contraction  is,  as  a  rule,  conducted  to 
the  ventricles  in  the  usual  manner,  setting  up  also  a  ventricular  contraction 
before  the  regular  time  for  it. 

Auricular  Flutter. — The  condition  known  as  auricular  flutter  is  one 
in  which  the  auricles  beat  regularly  at  a  very  rapid  rate,  usually  about  three 
hundred  times  per  minute,  while  ventricular  contractions  follow  every 
second,  third  or  fourth  auricular  contraction.  The  venous  tracing  which 
signifies  that  auricular  flutter  is  present  shows  a  series  of  rapidly  recurring 
waves  which  may  be  rather  poorly  defined,  and  only  every  second,  third, 
or  fourth  wave  will  be  followed  by  the  waves  of  ventricular  contraction. 
These  latter  waves  can  be  determined  by  comparing  the  venous  pulse  tracing 
to  the  tracing  from  the  radial  artery. 

Auricular  Fibrillation. — When  the  auricles  go  into  a  state  of  fibrillation, 
and  so  fail  to  contract  as  a  whole,  their  activity  is  such  that  no  definite 
waves  are  produced  in  the  jugular  tracing.  Then  the  "  C  "  and  " -  V  "  are 
present  without  the  normally  preceding  "  A  "  wave,  although  a  slight  un- 
dulation may  result  from  the  auricular  activity.    The  type  of  jugular  trac- 


Fig.  54. — Auricular  Fibrillation.  Polygraphic  tracing.  Apex  beat  above,  jugular  pulse  in  the  middle. 
Radial  pulse  below.  No  "A"  wave  is  seen.  The  arrhythmia  of  the  ventricles  is  indicated  by  the  time 
intervals  between  each  apex  beat  record. 

ing  is  spoken  of  as  the  ventricular  type  of  venous  pulse.  The  well-defined 
waves  that  appear  are  unusually  large,  as  a  rule,  and  occur  at  irregular  inter- 
vals. The  irregularity  of  the  heart  is  also  indicated  by  the  radial  tracings 
and  is  characterized  as  being  without  rule  or  rhythm.  It  is  known  as  the 
completely  irregular  pulse  to  which  has  been  given  the  name  pulsus  irregu- 
laris perpetuus.  The  absence  of  the  "A"  waves  and  the  complete  irregularity 
of  the  occurrence  of  waves  of  ventricular  activity  serve  to  establish  the 
diagnosis  of  the  frequent  and  important  form  of  disturbed  cardiac  action, 
auricular  fibrillation  (Fig.  54). 

Heart=Block. —  The  disturbances  of  condition  of  the  cardiac  impulse 
from  auricles  to  ventricles  vary  in  degree  from  a  mere  delay  to  a  complete 
cessation  of  conduction.  If  the  passage  of  the  impulse  is  delayed  owing  to 
a  lesion  in  the  conducting  system  between  the  auricles  and  ventricles,  the 
normal  time  interval  of  one-fifth  of  a  second  between  the  onset  of  the  "  A  " 
and  "C"  waves  will  be  lengthened  often  to  0.25  or  0.30  of  a  second.  If  the 
damage  to  the  conducting  system  is  such  that  at  times  auricular  impulses 
fail  to  reach  the  ventricles,  "A"  waves  without  the  accompanying  "  C  " 
waves  wili>appear,  and  the  condition  of  partial  heart-block  can  be  diagnosed 
from  the  record  (Fig.  55).    In  this  condition  two  "A"  waves  may  appear 


PHYSICAL  DIAGNOSIS:    MENSURATION. 


Ill 


before  each  "  C  "  wave,  when  the  so-called  two-to-one  rhythm  is  present, 
or  three  "A"  waves  may  be  present  before  each  "  C  "  wave,  indicating  that 
only  every  third  auricular  beat  succeeds  in  stimulating  a  ventricular  con- 
traction. If  a  mild  grade  of  partial  heart-block  is  present,  there  will  be  a 
gradual  lengthening  in  the  A-C  intervals  until  finally  an  "A"  wave  fails 
to  be  followed  by  a  ' '  C  "  wave.  This  event  is  followed  by  a  much  shortened 
A-C  interval,  owing  to  the  improvement  in  conduction  resulting  from  the 
rest  the  conducting  system  has  had.  Then  the  gradual  lengthening  ending 
in  another  "  A "  without  a  ' '  C  "  wave  again  takes  place. 


Uu.au.lo-Y      p"-I.Sfc 


Brdch.o.1   V".lse       "rW<*l    K«*«#  BUci 


Fig.  55. — Partial  heart-block.     Polygraph  tracing  from  the  jugular  vein  and  brachial  artery  showing  two- 
to-one  rhythm. 

When  there  is  complete  heart-block,  owing  to  a  lack  of  physiological 
continuity  between  the  auricles  and  ventricles,  the  "A"  waves  of  the  venous 
record  will  occur  independently  of  the  "  C  "  waves,  and  at  a  mucb  faster 
rate  than  the  unusually  slow  rate  of  appearance  of  the  "C"  waves  (Fig.  56). 
Such  a  record  is  characteristic  of  Complete  heart-block,  and  serves  to 
explain  the  bradycardia  which  results  from  the  slow  rate  of  contraction 
which  the  ventricles  maintain  when  beating  independently  of  the  auricles. 


1  [G     V,. — Complete    heart-blook.      Polygraphic   tracing,   jugular   vein   above,  radial    vein   below.     Wavea 
marked  "a"  represent  auricular  contractions. 

Extrasystoles  or  premature  beats  of  the  ventricles  occur  when  im- 
pulses arise  in  the  ventricles  independently  of  the  normally  descending 
cardiac  impulse.  This  condition,  resulting  from  sua  increase  in  the  irrita- 
bility of  the  ventricular  musculature,  may  be  thought  of  as  "cardiac 
impatience,"  the  ventricles  refusing  to  wait  for  the  normal  impulse  and 
going  into  contraction  prematurely.  These  premature  beats  usually  occur 
without  disturbing  the  rhythmical  auricular  activity.  The  characteristic 
venous  pulse  yielded  by  such  a  disturbance  of  the  heart  shows  a  "C" 
wave  occurring  without  a  preceding  "A"  wave  which  may  follow  it  and 
fall  with  the  "V"  wave  or  even  after  it.  The  "A"  waves  continue  to 
occur  at  regular  intervals,  and  those  that  fall  near  the  premature  "  C  " 


112  MEDICAL  DIAGNOSIS. 

waves  are  not  followed,  as  a  rule,  by  "  C  "  waves,  as  the  ventricles  fail  to 
respond  on  account  of  the  contraction  which  they  have  just  made.  Follow- 
ing a  premature  ventricular  beat  or  extrasystole,  the  ventricles  remain  in 
diastole  until  stimulated  by  the  auricular  contraction  which  follows  that 
occurring'  just  after  the  premature  ventricular  beat.  As  the  auricular 
rhythm  is  undisturbed  the  ventricular  rhythm  is  again  reestablished.  This 
fact  gives  a  certain  regularity  to  the  disturbance  of  rhythm  caused  by  pre- 
mature ventricular  beats.  The  shortened  diastole  preceding  the  premature 
beat,  and  the  lengthened  diastole  following  it,  are  together  equal  to  two 
regular  cardiac  cycles,  as  the  length  of  both  these  intervals  is  determined 
by  the  regularly  beating  auricles.  On  this  account  the  venous  pulse  tracing 
and  the  arterial  tracing  will  showtime  intervals  which  are  quite  characteristic 
of  ventricular  premature  beats  or  extrasystoles,  and  which  are  very  helpful 
in  the  diagnosis  of  this  common  disturbance  of  the  heart-beat.  Premature 
ventricular  beats  may  occur  occasionally  or  very  frequently,  and  at  times 
they  follow  every  normal  ventricular  beat  that  occurs,  giving  rise  to  the 
bigeminal  pulse,   every  alternate  ventricular  contraction   being  replaced 


Fig.  57. — Premature   ventricular   beats   or  extrasystoles.     Polygraphic  tracing  showing  a  premature  beat 
after  each  normal  beat.     The  premature  beats  produce  practically  no  waves  in  the  carotid  pulse  tracing. 

by  a  premature  beat.  This  condition  is  readily  recognized  by  the  study  of 
the  polygraphic  record  (Fig.  57). 

Graphic  records  of  circulatory  activity  are  useful  in  recording  the 
very  rapid  cardiac  rate  which  occurs  in  paroxysm  tachycardia,  and  which 
may  be  difficult  to  count  with  the  palpating  finger.  Here  the  radial  tracing 
alone  suffices.  They  are  also  useful  in  recording  pulsus  alternans,  in  which 
weak  and  strong  arterial  pulsations  alternate.  This  condition,  which  is  indic- 
ative of  a  grave  lesion  of  the  myocardium,  may  give  rise  to  alternating  large 
and  small  waves  in  the  radial  record,  and  the  venous  pulse  record  serves 
to  distinguish  it  from  the  bigeminal  pulse  caused  by  ventricular  extrasystoles, 
which  may  be  readily  confused  with  pulsus  alternans.  This  distinction  is 
of  importance  on  account  of  the  great  difference  in  prognostic  significance 
of  the  two  conditions. 

The  use  of  the  polygraph  requires  considerable  practice,  and  in  the 
hands  of  the  unskilled  or  of  the  impatient  physician  will  be  disappointing. 
An  assistant  is  often  necessary  for  its  proper  use,  especially  for  a  beginner ; 
but  persistence  and  practice  will  finally  yield  results  which  will  warrant 
all  the  time  and  energy  which  may  be  necessary  to  perfect  the  technique. 

The  Electrocardiograph. —  The  introduction  of  the  electrocardiograph 
for  the  purpose  of  studying  the  cardiac  movements  of  man  has  greatly  ex- 


PHYSICAL  DIAGNOSIS:    MENSURATION. 


113 


tended  our  conceptions  of  the  normal  cardiac  functions  and  has  shed  a  clear 
light  on  the  various  disturbances  of  the  heart  action.  The  credit  for  this 
achievement  belongs  to  Einthoven  of  Leyden,  who  described  this  new  instru- 
ment in  1903.  It  was  not  until  about  1909,  however,  that  several  workers 
began  to  use  the  instrument  and  to  apply  it  as  a  diagnostic  aid  in  clinical 
medicine.  At  this  time  the  first  instrument  was  brought  to  the  United  States 
by  Walter  B.  James  and  operated  by  H.  B.  Williams  and  himself.  During 
the  brief  period  of  less  than  ten  years  it  has  proved  of  great  value  both  for 
purposes  of  physiological  research  and  for  clinical  study.    The  electrocardio- 


B 


Fir;.  58. — A  diagram  illustrating  the  development  and  subsidence  ol  activity  (and  negative)  in  a  single 
musde strip,  responding  to  a  stimulus  applied  at  IJ.  The  corresponding  and  -um-in'  phases  of  the  gal- 
va  non  lit  in-  curve  are  shown  in  the  four  lines,  .-1,  B,  C,  and  D.  —  lAftei   Lewis), 


graph  lias  tlic  disadvantages  of  being  stationary,  expensive,  and  requiring 
considerable  training  for  its  proper  operation.  It  is,  therefore,  largely  of  use 
in  hospitals.  An  understanding  of  the  records  obtained  by  this  instrument  is 
in  eessary,  however,  to  rein |  intelligently  much  of  tin-  recent  literature  dealing 
with  cardiac  disease.  In  the  following  discussion  technicalitieswil]  he  included 
only  so  far  as  necessary  \'t>r  an  understanding  of  the  records.  For  a  com- 
plete explanation  of  the  electrocardiographic  method  special  hooks  and 
papers  tin  the  subject  must  he  consulted.  (Lewis,  Clinical  Electrocardi- 
ography. 

The  string  galvanometer,  that  pari  of  the  electrocardiograph  to  which 
8 


114  MEDICAL  DIAGNOSIS. 

all  others  are  accessory,  is  an  instrument  for  measuring  and  recording 
electrical  currents,  and  its  chief  merits  are  its  capability  of  indicating 
minute  electric  currents  and  of  recording  a  rapidly  changing  series  of  cur- 
rents. When  a  current  passes  through  the  very  fine  filament  of  the  instru- 
ment, this  filament  is  deflected  to  one  side  or  the  other,  depending  upon 
whether  the  current  passes  up  or  down  the  filament.  In  making  an  electro- 
cardiogram the  patient  is  put  in  circuit  with  this  very  delicate  filament, 
which  is  moved  back  and  forth  by  the  series  of  currents  which  are  generated 
by  the  contractions  of  the  cardiac  muscle.  It  is  a  well-known  phenomenon 
of  muscular  contraction  that  the  point  in  any  muscle  at  which  a  contraction 
starts  has  a  negative  electrical  potential  when  compared  with  the  uncon- 
tracted  part  of  the  muscle.  If  a  conductor,  such  as  a  wire,  is  attached  to 
the  two  ends  of  the  muscle,  a  current  will  pass  from  the  part  which  is  at 
rest  to  the  part  which  has  gone  into  contraction,  and  will  continue  to  pass 
until  the  whole  muscle  has  gone  into  contraction,  when  the  electrical  potential 
becomes  again  equalized,  just  as  it  was  when  the  muscle  was  at  rest.  When 
the  part  of  the  muscle  which  first  went  into  contraction  now  relaxes,,  a  cur- 
rent will  pass  through  the  conductor  in  the  opposite  direction,  because  again 
one  end,  now  the  opposite  end,  of  the  muscle  is  electrically  negative  to  the 
relaxed,  non-contracting  end.  When  relaxation  is  complete  no  more  current 
passes.  These  facts  are  diagrammatically  shown  by  the  accompanying  figure 
taken  from  Lewis  (Fig.  58). 

A  point  to  be  borne  in  mind  is  that  the  electric  currents  which  are  gen- 
erated by  the  contractions  of  the  heart  muscle  become  evident  only  when 
a  conducting  system  is  led  from  one  point  on  the  body-surface  to  another 
and  the  recording  apparatus  is  placed  in  the  circuit.  The  conducting  system 
is  so  attached  to  the  body  that  one  contact  leads  off  from  the  base  of  the 
heart  while  the  other  leads  off  from  the  apex.  As,  of  course,  the  contacts 
can  not  be  made  directly  911  the  heart  in  man,  the  body  tissues  themselves 
are  used  as  the  conductor  between  the  heart  and  the  actual  point  of 
contact.  The  two  arms  and  the  left  leg  are  used  as  the  points  of  contact,  and 
wires  are  attached  to  these  parts  by  means  of  easily  applied  conductors. 
In  making  the  records,  of  course,  but  two  contacts  are  used  at  a  time,  but 
by  first  using  the  two  arms,  then  the  right  arm  and  left  leg,  and  lastly,  the 
left  arm  and  leg,  the  three  usual  first,  second,  and  third  leads  are  obtained. 
Currents  pass  back  and  forth  from  these  points  of  contact  during  each 
cardiac  contraction,  and  so  the  string  of  the  galvanometer  is  moved. 

When  the  heart  is  beating  normally  a  current  is  generated,  first  by  the 
contraction  of  the  auricles,  which  causes  a  characteristic  deflection  of  the 
string,  then,  after  a  short  pause,  during  which  time  the  impulse  of  contrac- 
tion is  passing  down  from  the  auricles,  the  ventricles  go  into  contraction,  and 
a  series  of  movements  is  set  up.  The  complexity  of  these  movements  is 
due  to  the  complexity  of  the  muscular  arrangement  of  the  ventricles  and 
the  complicated  muscular  contractions  that  go  to  make  up  ventricular 
systole.  The  movements  of  the  string  are  recorded  by  throwing  its  shadow 
upon  a  moving  photographic  film  or  paper,  the  shadow  of  a  time-marker 
being  thrown  upon  the  recording  surface  at  the  same  time.  The  movements 
of  the  string  are  in  this  way  converted  into  a  record  which  consists  of  a 


PHYSICAL  DIAGNOSIS:    MENSURATION. 


115 


series  of  waves.  These  waves  are  usually  five  in  number,  three  positive  and 
two  negative,  designated  arbitrarily  P,  Q,  R,  S,  and  T.  The  P  wave 
represents  the  auricular  contraction  and  can  be  readily  distinguished  from 
the  Q,  R,  S,  and  T  group  that  represents  the  ventricular  contraction 
(Fig.  59). 

The  length  of  the  circuit  from  one  side  of  the  patient's  body  to  the 
string  galvanometer  and  back  to  the  other  side  of  the  body  has  practically 
no  influence  on  the  type  of  record  obtained.    For  this  reason  it  is  not  neces- 

■■■■■ 


bia.  59. — Electrocardiogram  of  a  normally  beating  heart, 

Bary  to  have  the  patient  near  the  galvanometer,  provided  wires  can  be  Led 
between  the  patient  and  the  instrument. 

The  fad  that  in  the  electrocardiogram  the  record  yielded  by  the  auricu- 
lar activity  can  he  readily  distinguished  from  the  record  of  ventricular  activ- 
ity is  d!'  great  importance,  and  allows  the  various  disturbances  of  the  heart- 
beat to  be  identified  with  certainty.  The  Eorm  of  the  record  produced  by 
both  auricular  and  ventricular  activity  is  altered  whenever  the  passage  of 
the  cardiac  impulse  follows  an  abnormal  course,  so  that  striking  changes 
in  the  form  of  the  curves  occur  whenever  a  cardiac  impulse  arises  in  an 


116. 


MEDICAL  DIAGNOSIS. 


abnormal  point  and  so  courses  over  the  heart  along  abnormal  paths  or  in  an 
abnormal  direction.  Thus  the  occurrence  of  a  so-called  ectopic  impulse  is 
recognized,  whether  it  arises  in  the  auricles  or  in  the  ventricles.  Changes 
in  the  form  of  the  curve  also  take  place  whenever  the  muscle  mass  on  the 
two  sides  of  the  heart,  especially  in  the  ventricles,  is  disturbed  by  hyper- 
trophy. 

The  electrocardiographic  records  obtained  from  the  commoner  forms 
of  deranged  cardiac  mechanism  will  be  discussed.  They  are  best  classified 
by  the  various  regions  of  the  heart  affected,  and  include  the  disturbances 
of  the  (a)  sinus  region,  (b)  the  auricles,  (c)  the  auriculo-ventricular  con- 
ducting system,  and  (d)  the  ventricles. 

The  disturbances  in  these  various  parts  of  the  heart  may  be  taken  up 
just  as  they  have  been  when  the  polygraph  was  under  consideration. 

(a)  The  activity  of  the  sinus  region,  where  the  cardiac  impulse  arises, 
is  not  indicated  in  the  human  electrocardiogram,  so  that  any  disturbance 
of  impulse  formation  in  this  region  is  only  indicated  by  the  irregularity  at 
which  the  normal   auricular  and  ventricular  waves  appear.     When  the 


"    -A.  P  m  'ka^L 


Fig.  60. — Premature  ectopic  auricular  beats  or  auricular  extrasystoles.  Electrocardiogram  shows  two 
downwardly  directed  auricular  waves,  occurring  permaturely.  They  indicate  that  the  impulse  has  arisen 
near  the  base  of  the  auricles.     Only  one  of  the  two  ectopic  beats  stimulates  a  ventricular  contraction. 

diastolic  portions  of  the  electrocardiogram  vary  from  beat  to  beat,  sinus 
arrhythmia  is  present,  a  condition  which  is  in  itself  without  pathological 
significance. 

(b)  The  contraction  of  the  auricles  yields  a  small,  rounded,  character- 
istic, upward  wave  when  the  auricles  are  stimulated  by  an  impulse  from  the 
sinus  region.  The  form  of  the  wave  is  quite  changed  if  the  impulse  arises  else- 
where. If  it  should  arise  near  the  lower  part  of  the  auricles  instead  of  in 
the  sinus  region,  it  would  travel  upward  instead  of  downward,  and  the 
auricular  musculature  would  pass  into  contraction  in  a  direction  opposite 
to  the  normal.  This  ectopic  contraction  would  yield  a  downwardly  directed 
wave  instead  of  an  upwardly  directed  wave.  This  impulse  reaching  the 
sinus  region  would  disturb  the  rhythm  of  impulse  formation  normally 
taking  place  there,  and  an  irregularity  of  the  heart  would  result  (Fig.  60). 

Impulses  may  arise  from  an  ectopic  focus  at  a  very  rapid  rate,  often  at 
about  two  hundred  times  a  minute,  thus  giving  rise  to  tachycardia  of 
auricular  origin,  such  as  occurs  in  paroxysmal  tachycardia.  This  condition 
yields  a  characteristic  record,  recognized  particularly  by  the  high  cardiac 
rate. 

Another  type  of  disturbed  auricular  activity  is  that  known  as  auricular 
flutter,  in  which  the  auricles  contract  with  a  still  higher  rate.    The  auricular 


PHYSICAL  DIAGNOSIS:    MENSURATION 


117 


rate  may  be  over  three  hundred  per  minute,  and  when  such  a  rate  is 
attained,  it  is  usually  accompanied  by  a  varying  degree  of  partial  heart- 
block,  only  every  second  or  third  auricular  contraction  sending  an  impulse 
to  the  ventricles  (Fig.  61). 

Auricular  fibrillation,  the  most  frequent  type  of  disturbed  cardiac 
mechanism  in  patients  with  broken  cardiac  compensation,  is  clearly  demon- 
strated by  the  electrocardiogram.  In  this  condition  the  auricles  no  longer 
contract  as  a  whole,  but  the  various  muscle  bundles  composing  the  auricular 
walls  contract  and  relax  independently  of  one  another,  giving  rise  to  a 


*A** 


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w^w^» 


Wv"*  >pt|j|fl*  >»*^1  «yMi  V* 


I  i'..  61.  —  Auricular  flutter.    Electrocardiogram  in  which  the  auricular  wavee  occur  al  a  rate  of  338  and 
the  ventricular  waves  al  a  rate  oi   L69  per  minute. 

chaotic,  incessant  activity  in  the  auricles.  This  causes  the  ventricles  to  con- 
tract al  irregular  intervals,  ami  is  responsible  for  the  absolutely  irregular 
puis..  Electrocardiograms  from  patients  with  auricular  fibrillation  fail 
to  show  the  regularly  recurring  series  of  "  P  "  waves  of  auricular  contrac- 
tion which  normally  precede  each  group  of  waves  of  ventricular  origin. 
Instead   there   is  a   series   of   small    irregular   waves   which   are   seen    in    all 

parts  of  the  curve  representing  ventricular  diastole.  The  occurrence  of 
these  small  irregular  waves,  together  with  the  irregular  occurrence  of  the 
ventricular  group  of  waves,  constitutes  the  typical  electrocardiogram  of 
auricular  fibrillation  (Fig.  62).    The  electrocardiogram  is  the  clearesl  and 

most  definite  means  of  recognizing  this  condition. 


118 


MEDICAL  DIAGNOSIS. 


(c)  Disturbances  of  conduction  of  the  cardiac  impulse  from  auricles 
to  ventricles  are  shown  by  changes  in  the  relation  of  the  auricular  and  the 
ventricular  waves.  If  the  disturbance  is  such  that  the  cardiac  impulse 
is  delayed  in  its  passage  from  the  auricles  to  the  ventricles,  the  interval 
between  the  beginning  of  the  "P"  wave  (auricular)  and  the  beginning 
of  the  "  Q  "  or  "  R  "  wave  (ventricular)  is  lengthened.  Normally  the  so- 
called  P-R  time  is  0.17  second  or  less,  and  whenever  it  exceeds  this  time 


•*.* ;  „ktu«^L 


Xnc4  l«.<2Lol 


M^W^j^A^^i 


fpsil 


^jiJ\1^^4 


pIG  62  — Auricular  fibrillation.  Electrocardiogram  showing  the  absence  of  "P"  waves,  the  irregular- 
ity of  the  ventricular  waves,  and  the  small  irregular  waves  yielded  by  the  fibrillatifag  auricles  during 
ventricular  diastole. 

there  is  a  delay  in  conduction.  By  this  means  slight  impairment  of  the 
auriculo-ventricular  conducting  system  (the  bundle  of  His)  is  revealed 
(Fig.  63). 

When  the  ability  to  conduct  the  cardiac  impulse  from  auricles  to 
ventricles  is  further  impaired,  various  grades  of  heart-block  occur.  This 
may  result  in  an  occasional  auricular  beat  that  is  not  followed  by  a  ventric- 
ular contraction,  or  the  defect  in  conduction  may  be  so  great  that  only 
every  second  or  third  auricular  contraction  sets  up  a  ventricular  beat. 


PHYSICAL  DIAGNOSIS:    MENSURATION. 


119 


These  conditions  are  recognized  at  a  glance  when  an  electrocardiogram  is 
obtained,  the  "  P  "  waves  of  auricular  origin  being  readily  distinguished 
from  the  tall  "R"  waves  of  ventricular  origin  (Fig.  64).  If  there  is  a 
complete  physiological  separation  of  the  two  parts  of  the  heart  resulting 
in  complete  heart-block,  the  record  shows  the  waves  of  auricular  and  ventric- 
ular origin  occurring  quite  independently  of  one  another  and  at  an  entirely 
different  rate.  Not  infrequently  the  ventricular  complexes  have  an  abnormal 
form,  probably  indicating  that  the  passage  of  the  cardiac  impulse  from 
its  origin  in  the  basal  portion  of  the  ventricles  is  being  hindered  in  its  passage 


Fig.  63. — Delayed  conduction.     Electrocardiogram  showing  prolongation  of  P-R  time  marked  in  seconds. 

through  the  ventricles,  as  the  result  of  the  same  lesion  which  prevents  the 
passage  of  the  cardiac  impulse  from  auricles  to  ventricles  (Fig.  65). 

(d)  A  very  common  form  of  cardiac  irregularity  is  the  result  of  the 
spontaneous  generation  of  impulses  in  the  ventricles,  which  set  up  premature 
ventricular  contractions.  When  this  occurs  the  impulse  travels  through  the 
heart  in  an  abnormal  direction  and  along  abnormal  paths.  This  type  of 
cardiac  contraction  yields,  therefore,  an  abnormal  form  of  electrocardiogram 
and  the  form  will  vary  according  to  point  of  origin  of  the  impulse.  If  it 
arises  in  the  rifjht  ventricle  it  has  a  form  which  distinguishes  it  from  an 
impulse  arising  in  the  left  ventricle.    As  the  cardiac  contractions  occur  before 


Fig.  64. — Partial  heart-Work.     Electrocardiogram  showing  "P"  waves  unaccompanied  by  "R"  waves  and 
progressive  lengthening  of  the  P-R  intervals  until  the  block  occurs. 

the  regular  time,  they  are  spoken  of  as  premature  beats,  and  as  the  impulses 
arise  in  an  abnormal  point  they  are  known  also  as  ectopic.  The  term  ectopic 
premature  contractions  is  more  descriptive  than  the  older  and  better-known 
term  extrasystoles.  The  electrocardiogram  demonstrates  not  only  the 
presence  of  premature  ectopic  ventricular  beats  but  also  shows  the  time  rela- 
tions which  exist  between  this  type  of  beats  and  the  normal  contractions. 
The  auricular  rhythm  is  not  disturbed,  hut  the  auricular  contraction,  which 
usually  occurs  almost,  synchronously  with  the  premature  ectopic  ventricular 
beat,  fails  to  produce  a  ventricular  response,  as  the  refractory  phase  of  the 
ventricles  has  not  passed  off  when  the  impulse  from  the  auricles  reaches  it. 
For  this  reason  there  is  a  pause  in  the  ventricular  rhythm,  and  no  contrac- 


120 


MEDICAL  DIAGNOSIS. 


tion  takes  place  until  the  next  auricular  contraction  sends  down  its  impulse 
to  the  ventricles.  The  pause  and  the  unusually  short  period  of  diastole 
which  precedes  the  premature  beat  are,  therefore,  of  the  same  duration  as  two 
normal  cardiac  cycles.     This  is  a  point  well  shown  by  electrocardiograms 


_- Jrr 


-JL_      A    ___  f_  __ 


Fig.  65. — Complete  heart-block.  Electrocardiogram  showing  independent  occurrence  of  auricular 
and  ventricular  waves.  The  ventricular  portion  of  the  record  has  a  distinctly  abnormal  form  suggesting 
disturbance  of  the  passage  of  the  cardiac  impulse  through  the  ventricles.     From  a  child  with  diphtheria. 


^wW*^ 


jLn<l:-tta.4. 


%u0  "**"   ii  imiT*!^ 


j  o.<\\ 


Fig.  66. — Premature  ectopic  ventricular  beat.     Electrocardiogram  showing  the  abnormal  type  of  ventri- 
cular record  and  the  characteristic  time  relations. 


and  is  useful  in  making  a  diagnosis  of  premature  beats  of  ventricular  origin 
whether  this  is  done  by  the  ausculting  ear,  the  palpating  finger,  or  by  the 
study  of  electrocardiograms  (Fig.  66). 

The  variations  in  the  form  of  the  ventricular  portion  of  the  electro- 
cardiogram are  significant,  and  may  give  important  information  regarding 
the  physiological  state  of  the  ventricular  musculature.     This  is  especially 


PHYSICAL  DIAGNOSIS:    MENSURATION. 


121 


true  when  the  records  of  the  three  usual  leads  are  compared,  as  the  relative 
height  and  direction  of  the  main  wave  of  the  ventricular  complexes  in  the 
three  leads  are  altered  by  a  relative  increase  of  the  muscle  mass  in  the  right 
ventricle  as  compared  to  that  of  the  left.  When  the  left  ventricular  muscu- 
lature predominates,  a  change  in  the  opposite  direction  in  the  electrocardio- 
gram takes  place.  When  the  main  waves,  "R"  waves,  are  compared  in 
height  in  a  normal  record  (Fig.  59)  it  is  seen  that  they  are  upwardly  directed 


.3  y.  41.*  ad. 


t*v^k.   *h    'Vv<*>V« 


r* 

mm±ummm  ■ 

H 

1  i'..  67.  —Hypertrophy  of  the  right  ventricle.     Electrocardiogram  showing  the  main  wavi 
tncular  record  downwardly  directed  in  the  first  lead  and  nigheal  in  the  third  lead.     From  a  case  of  mitral 

Minimis. 


in  all  leads,  thai  the  second  lead  is  as  tall  as  the  firsl  and  third  added 
together,  and  that  the  first  is  slightly  taller  than  the  third  lead. 

When  there  is  hypo-trophy  of  the  right  ventricle  the  first  lead  usually 
shows  a  downwardly  directed  main  wave,  while  the  third  lead  shows  a  main 
wave  which  is  taller  than  that  of  the  second  lead.  This  relation  of  the  three 
waves  occurs  practically  exclusively  in  cases  with  mitral  steimsis  or  congenital 
heart  disease,  and  such  a  finding  is  frequently  of  distinct  diagnostic  value 
(Fig.  67). 


122 


MEDICAL  DIAGNOSIS. 


With  hypertrophy  of  the  left  ventricle  the  main  wave  of  the  first  lead 
is  tallest,  while  the  main  wave  of  the  second  and  third  leads  may  be  down- 
wardly directed  that  of  the  third  lead  always  being  deeper  than  that  of  the 
second  lead.  The  electrocardiograms  from  patients  with  arterial  hyperten- 
sion or  aortic  insufficiency  usually  show  such  a  relationship  between  the 
main  ventricular  waves  of  the  three  leads,  and  the  degree  of  preponderance 


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Fig.  68. — Hypertrophy  of  the  left  ventricle.  Electrocardiogram  showing  the  main  wave  of  the  ven- 
tricular record  highest  in  the  first  lead  and  downwardly  directed  in  the  third  lead.  From  a  case  of  arterial 
sclerosis  with  hypertension. 

of  the  left  over  the  right  ventricular  muscle  mass,  can  be  judged  from  the 
forms  of  the  electrocardiograms  (Fig.  68). 

The  interpretation  of  electrocardiograms  of  atypical  forms  presents  a 
problem  which  is  as  yet  not  entirely  solved,  but  to  the  experienced  eye  many 
abnormal  forms  of  records  are  significant.  Cases  of  damaged  myocardium 
often  yield  records  in  which  the  final  ventricular  wave,  the  "  T  "  wave,  is 
downwardly  directed  in  the  first  and  second  leads.  These  cases  may  also 
yield  very  small  complexes,  indicating  that  the  electrical  potential  generated 
by  the  heart-beat  is  abnormally  low.     The  atypical  forms  of  electrocardio- 


PHYSICAL  DIAGNOSIS:    MENSURATION. 


123 


grams  may  be  the  result  of  delayed  or  blocked  cardiac  impulses  while  passing- 
through  parts  of  the  ventricles.  There  may  be  a  block  in  one  or  the 
other  of  the  branches  of  the  conducting  system  along  which  the  impulse  is 
conveyed  to  the  ventricles,  and  when  this  occurs,  a  characteristic  form  of 
electrocardiogram  results,  varying  with  the  position  of  the  block.  Dis- 
turbances of  conduction  in  the  less  specialized  parts  of  the  ventricles  may 


Fi<;.  69.— Electrocardiogram  of  abnormal  form  from  a  case  of  chronic  myocarditis.  Widening  and 
notching  of  the  Q-R-S  group  of  waves  in  each  lead;  indicating  that  tin-  cardiac  impulse  travels  through 
the  ventricles  along  abnormal  paths  or  at  an  abnormal  rate. 


also  be  suspected  from  the  form  of  the  records  (Fig.  69).  The  value  of  tin- 
electrocardiogram  as  indicative  of  the  functional  efficiency  of  the  heart  is  not 
as  yet  definitely  established,  but  the  growing  knowledge  of  the  significance  in 
form  of  the  curves  in  the  three  usual  leads  is  bringing  a  closer  correlation 
between  the  functional  activity  of  the  heart  and  the  form  of  the  electro- 
cardiogram. 

Instruments  for  Measuring  the  Arterial  Blood=Pressure. — Blood-pres- 
sure is  the  force  exerted  by  the  blood  against  the  blood-vessel  wall  (lateral 


124  MEDICAL  DIAGNOSIS. 

pressure)  or  the  force  upon  the  blood  cirrent  lying  in  front  of  it  (end 
pressure).  It  depends  upon  four  separate  factors:  (a)  the  energy  of  the 
heart;  (b)  the  peripheral  resistance;  (c)  the  elasticity  of  the  blood-vessel 
walls;  (d)  the  volume  of  the  circulating  blood.  One  or  all  of  these  factors 
may  vary  under  normal  conditions.  They  may  be  greatly  altered  in  j3atho- 
logical  states. 

The  Systolic  Pressure  (maximal  pressure)  is  the  highest  point  reached 
in  the  artery  during  the  ventricular  systole.  The  Diastolic  Pressure  (mini- 
mal pressure)  is  the  lowest  point  reached  within  the  artery  during  the 
diastole  of  the  ventricle.  It  is  the  peripheral  resistance  which  the  heart  has 
overcome  and  which  is  maintained  in  the  peripheral  circulation  during 
diastole.  The  Pulse  Pressure  is  determined  by  subtracting  the  minimal 
from  the  maximal  pressure.  The  average  pressure  during  a  certain  period 
is  called  the  mean  pressure. 

The  Sphygmomanometer  is  an  instrument  used  to  determine  the  blood- 
pressure.  The  essential  parts  comprise  a  compressing  armlet  having  a 
breadth  of  not  less  than  8  cm.,  non-distensiie  connecting  tubes,  an  inflating 
apparatus  and  the  manometer.  Two  types  of  the  last  are  in  general  use, 
the  mercury  manometer  and  the  aneroid  manometer.  The  latter  is  more 
conveniently  portable  but  requires  occasional  adjustment  on  comparison  with 
an  instrument  of  the  former  type.  The  newer  instruments  permit  the 
determination  of  both  the  systolic  and  diastolic  pressure.  The  mechanical 
principle  is  the  indication  by  the  manometer  of  the  pressure  necessary  to 
cause  obliteration  of  the  arterial  pulse.  Clinically  we  measure  the  arterial 
pressure  in  the  brachial  artery,  and  the  venous  pressure  in  the  veins  of  the 
hand  or  at  the  elbow.  It  is  well  to  adopt  some  method  to  determine  all  pres- 
sures, thus  eliminating  error  and  loss  of  time.  Preferably,  the  patient  should 
be  recumbent.  The  right  or  left  arm  may  be  used.  The  muscles  should  be 
relaxed  since  contractions  are  manifest  on  the  manometer.  The  first  esti- 
mation may  be  found  10  to  20  millimeters  higher  than  subsequent  readings, 
a  variation  probably  due  to  excitement  or  fear  of  pain. 

Repeated  or  control  observations  should  be  made.  In  cases  of  threatened 
circulatory  failure  it  is,  at  times,  practically  impossible  to  get  a  clear-cut 
high  or  low  pressure.  The  systolic  pressures  will  vary  from  5  to  15  milli- 
meters even  though  repeated  estimations  are  made.  These  cases  may,  at 
times,  show  a  condition  in  which  an  occasional  beat  comes  through  at  a  higher 
level  than  that  at  which  all  beats  can  be  detected.  The  respiratory  action  is 
often  the  causative  factor.  This  should  be  noted  thus — high  pressure,  occa- 
sional beat  at  170 ;  all  other  beats  at  155. 

A  description  of  the  various  instruments  supplied  by  the  dealers  is  not 
deemed  necessary  since  a  complete  explanation  accompanies  each  apparatus. 

The  Palpatory  Method. — The  patient  is  placed  in  the  recumbent  or  sit- 
ting posture  with  the  muscles  of  the  arm  completely  relaxed,  the  elastic  cuff 
is  closely  applied  to  the  bare  arm  above  the  elbow  and  distended  by  the 
means  of  inflating  apparatus  until  the  pulse  can  no  longer  be  detected  in  the 
radial  artery  by  the  finger  continuously  applied ;  the  pressure  is  now  grad- 
ually reduced  until  the  pulse  reappears.  The  point  indicated  on  the  mano- 
meter is  the  systolic  pressure.  The  diastolic  pressure  represents  the  greatest 
oscillation  recorded  by  the  manometer,  either  mercurial  or  aneroid,  as  the 
pressure  upon  the  artery  is  carefully  lowered.     This  procedure  is  probably 


PHYSICAL  DIAGNOSIS:    MENSURATION.  125 

the  best  way  of  determining  the  maximal  pressure,  while  the  auscultatory 
method  is  surely  the  preferable  one  to  ascertain  the  minimum  pressure. 

The  Auscultatory  Method. — The  cuff  is  applied  over  the  brachial  artery, 
as  already  described  under  the  palpatory  method,  and  pressure  in  it  raised 
until  the  radial  pulse  disappears.  The  bell  of  a  binaural  stethoscope  is 
placed  over  the  artery  below  the  cuff  without  pressure.  The  air  is  gradually 
released  and  usually  at  the  moment  the  pulse  is  felt  at  the  wrist  one  will  hear 
a  slight  tone  which  corresponds  to  the  maximal  pressure.  As  the  pressure 
is  further  reduced  the  tones  accompanying  the  pulse-beats  grow  louder  and 
are  sometimes  accompanied  by  blowing  murmurs.  A  point  of  maximal  in- 
tensity is  finally  reached,  at  which  junction  the  sounds  suddenly  become 
feebler  and  soon  entirely  disappear.  This  junction  corresponds  to  the 
minimal  blood-pressure. 

Goodman  and  Howell  have  called  attention  to  the  remarkable  cycle  of 
auditory  phenomena  which  correspond  to  the  degrees  of  pressure  as  shown  by 
the  manometer  and  they  have  divided  them  into  five  distinct  phases.  When 
the  pressure  is  normal — systolic  130  mm.  and  diastolic  85  mm. — these  phases 
are  well  defined  and  bear  a  definite  relation  to  the  differences  between  the 
extremes  of  pressure.    They  are  as  follows : 

1.  A  loud,  clear,  snapping  sound  ascribed  to  sudden  distention  of  the 
artery  by  the  inrushing  blood.  This  sound  is  not  unlike  that  of  the  first 
sound  of  the  heart. 

2.  A  series  of  hissing  murmurs  are  heard  accompanying  the  first  phase 
sound,  due  to  the  formation  of  "fluid  veins"  as  the  blood  flows  through 
the  constriction  into  the  wider  vessel  beyond. 

3.  These  murmurs  disappear  suddenly  and  a  tone,  usually  much  louder 
than  that  of  first  phase,  is  heard.  It  is  the  sign  of  reestablished  blood  flow 
in  the  artery  corresponding  to  the  disappearance  of  the  "fluid  vein"  due 
to  the  lessening  of  the  pressure  constriction  upon  the  artery. 

4.  At  the  end  of  the  third  phase  the  sound  suddenly  becomes  muffled 
in  character.     This  point  corresponds  to  the  minimal  pressure  in  the  artery. 

5.  The  fourth  phase  is  very  short  and  at  the  end  of  it  all  sounds  cease. 
Pachon's  Sphygmometric  Oscillometer. — This  instrument,  constructed 

on  the  aneroid  principle,  is  much  more  convenient  and  sensitive  and  fully 
as  accurate  as  the  mercurial  devices.  In  ordinary  practice  the  cuff  is  applied 
at  the  wrist.    The  details  of  the  technic  accompany  each  instrument. 

The  Blood=Pressure  under  Normal  Conditions. — The  average  systolic 
blood-pressure  in  the  healthy  young  adult  (20  to  25  years)  when  recumbent 
is  110  mm.;  the  diastolic,  65  mm.  and  the  pulse  pressure  35  mm.  The  upper 
and  lower  systolic  limits  in  health  are  about  145  mm.  and  80  mm.  respec- 
tively. The  pressure  in  females  is  about  10  mm.  lower.  The  pressure  after 
fifty  is  higher,  while  the  pressure  in  infants  is  about  80  mm.  The  normal 
pressure  is  influenced  by  physiological  conditions.  It  is  higher  when  erecl 
than  when  recumbent,  after  eating;  after  mental  and  physical  exertion 
providing  they  are  not  carried  to  the  point  of  fatigue;  the  latter  causes  a 
fall  in  pressure.  Sleep  causes  a  Blight  fall  in  the  systolic  and  a  marked  fall 
in  the  diastolic  pressures 

The  Blood=Pressure  in  Pathological  States.  High  Blood=Pressure — 
Hypertension. — The  highesi  recorded  arterial  pressures  have  occurred  in 
acute  compression  of  the  brain,  such  as  is  caused  by  intracranial  hemorrhage 


126 


MEDICAL  DIAGNOSIS. 


or  fracture  of  the  base  of  the  skull.  Chronic  arterial  hypertension  occurs 
in  cases  of  intracranial  pressure  due  to  meningitis  and  tumor.  As  a  general 
rule  persons  who  become  hemiplegic  in  consequence  of  thrombosis  or 
hemorrhage  have  previously,  if  examined,  manifested  sclerosis  of  the  peri- 
pheral vessels  with  hypertension.  The  apoplectic  shock  is  attended  with  tem- 
porary hypotension. 

Chronic  Renal  Disease. — Permanent  high  pressure  is  a  conspicuous 
phenomenon  in  chronic  interstitial  nephritis.  Systolic  pressures  of  200  mm. 
and  more  are  common.  Diastolic  pressures  are  usually  60  to  80  mm.  lower. 
The  facts  have  great  value  in  diagnosis.  There  are,  however,  cases  of  inter- 
stitial nephritis  in  which  high  arterial  pressure  does  not  occur.  They  are 
those  with  associated  severe  wasting  diseases,  thosa  in  which  there  is  late 
cardiac  insufficiency,  and  those  that  have  reached  the  terminal  stages  of 
the  disease.  In  chronic  parenchymatous  nephritis  high  tension  also 
occurs,  but  isi  by  no  means  so  constant  as  in  the  interstitial  form.  In  amy- 
loid disease  blood-pressure  is  inconstant,  sometimes  high,  sometimes  sub- 
normal. 

Uremia.- — The  symptoms  of  this  condition,  especially  in  its  chronic 
form,  are  associated  with  increased  blood-pressure  and  become  more  marked 
as  the  tension  rises,  less  marked  as  it  falls.     Persistent  lower  tension  has 

followed  improvement  under  treatment.     A 
gradual  fall  has  preceded  death. 

Arteriosclerosis.  —  When  the  larger 
superficial  arteries  only  are  involved  the  blood- 
pressure  is  not  markedly  affected.  Arterio- 
sclerotic processes  generally  involving  the 
smaller  vessels  are  accompanied  by  increased 
blood-pressure,  the  systolic  pressure  being  in- 
creased much  more  than  the  diastolic.  There 
is  accordingly  a  high  pulse  pressure.  In  this 
form  of  arteriosclerosis  crises  of  vasoconstric- 
tion occur.  Such  vascular  crises  are  met  with 
also  in  tabes  and  chronic  lead  poisoning.  To 
this  group  of  paroxysmal  constriction  of  the 
vessels  must  be  referred  angina  pectoris, 
angina  abdominis  and  intermittent  claudication.  During  such  attacks 
patients  who  ordinarily  show  hypotension  may  register  very  high  arterial 
tension. 

Diseases  of  the  Heart. — In  primary,  uncomplicated  cardiac  insuf- 
ficiency from  myocardial  changes  high  normal  pressures  appear  to  be  the 
rule.  When  the  cardiac  insufficiency  is  due  to  failing1  compensatory  hyper- 
trophy in  arteriosclerosis  and  renal  disease,  the  blood-pressure  is  high.  As 
the  myocardium  becomes  feebler  the  arterial  tension  falls. 

Valvular  Disease. — In  aortic  insufficiency  the  sphygmomanometer, 
to  use  the  words  of  Janeway,  "gives  a  numerical  value  to  the  well-known 
pulsus  celer,  which  expresses  perfectly  the  mechanical  effect  of  the  lesion 
in  the  systemic  arterial  circulation."  The  systolic  pressures  are  high,  the 
diastolic  pressures  low.  In  combined  aortic  insufficiency  and  stenosis  the 
blood-pressure  determination  is  of  value  in  indicating  the  preponderating 
lesion,  a  high  degree  of  stenosis  being  accompanied  by  a  proportionately 


Fig.  70. — Faught  mercurial  sphygmo- 
manometer. 


FlQ.  71a. — Sanborn's  sphygmomanometer.     Auscultatory  method. 


Fia.  716. — Sanborn's  sphygmomanometer.    Palpatory  method. 


2ft 

m 

75>p 

1 

^y 

V 

_ . 

>Mi 

Fig.  72. — Paehon'B  sphygmometric  oscillometer. 


PHYSICAL  DIAGNOSIS:    MENSURATION.  127 

lower  systolic  pressure.  In  associated  aortic  and  mitral  insufficiency,  the 
degree  of  the  latter  defect  may  be  estimated  by  the  systolic  as  compared 
with  the  diastolic  blood-pressure.  In  disease  of  the  aortic  valves  the  systolic 
pressure  is  frequently  variable  in  the  absence  of  obvious  cause,  while  the 
diastolic  pressure  is  more  constant.  Sphygmomanometric  measurements  are 
of  less  value  in  other  forms  of  valvular  disease.  In  aortic  ins1  fficiency  there 
is  sometimes  a  great  difference  between  the  maximal  pressure  in  the  arm  and 
that  in  the  leg,  both  being  measured  while  the  patient  is  in  the  recumbent 
posture.  Normally  these  pressures  are  the  same.  Exophthalmic  goitre 
shows  as  a  rule  normal  pressure  or  hypotension.  The  relatively  infrequent 
cases  with  hypertension  usually  show  complicating  implication  of  the  heart, 
blood-vessels,  or  kidneys. 

Low  Blood=Pressure — Hypotension. — This  condition  is  present  in  wast- 
ing diseases  and  cachectic  states,  various  infections  and  toxaemias,  especially 
when  severe,  profuse  hemorrhage,  collapse  and  shock,  and  terminal  states — 
agonal  hypotension. 

Chronic  Diseases. — Phthisis  in  its  advanced  stages  and  Addison's 
disease  give  low  pressures.  In  the  early  stages  of  syphilis  when  there  is 
fever  and  the  condition  is  analogous  to  an  acute  infectious  process,  there  is 
hypotension.  Diabetes  is  apparently  without  direct  influence  upon  the 
blood-pressure.  When  associated  with  arteriosclerosis  or  chronic  renal  dis- 
ease it  may  show  hypertension,  and  in  advanced  cases  hypotension  is  common 
in  consequence  of  emaciation  and  cardiac  insufficiency.  The  secondary  anae- 
mias are  attended  by  low  blood-pressures;  derangements  of  pressure  in 
chlorosis  are  neither  marked  nor  characteristic.  Chronic  bronchitis,  emphy- 
sema and  asthma  are  frequently  attended  with  high  arterial  tension.  Pleural 
effusions  show  hypertension  which  falls  upon  aspiration. 

The  Acute  Infectious  Febrile  Diseases. — The  type  of  this  group, 
namely,  enteric  fever,  shows  with  great  constancy  low  pressure.  System- 
atic observations  at  regular  and  frequent  intervals  have  shown  that  hypo- 
tension is  first  apparent  toward  the  end  of  the  first  or  early  in  the  second 
week  and  increases  as  the  attack  goes  on.  The  daily  oscillations  are  not 
significant.  Crile's  statistics,  quoted  by  Janeway,  are  very  suggestive. 
The  mean  pressure  by  weeks  in  all  cases  was,  first  week,  115  mm.;  second 
week,  106  mm. ;  third  week,  102  mm. ;  fourth  week,  96  mm. ;  and  fifth  week, 
98  mm.  A  gradually  progressive  fall  indicates  increasing  failure  of  vaso- 
motor tonus;  a  sudden  fall,  actual  collapse  or  hemorrhage.  A  sharp  rise 
in  pressure  attends  the  occurrence  of  perforation.  These  facts  may  lie  of 
great  value  in  the  differential  diagnosis  between  collapse  from  hemorrhage 
or  other  cause  in  enteric  fever  ami  intestinal  perforation.  Continuous 
records  are  necessary.  In  the  terminal  stage  of  the  consecutive  peritonitis 
hypotension  becomes  extreme — agonal  fall  of  pressure. 

PNEUMONIA. — Uniform  tendencies  in  blood-pressure  have  not  been 
observed.  Subnormal  pressures  are  common;  in  severe  eases  the  ride.  A 
rapid  fall  may  precede  collapse  or  the  fatal  issue.  When  arterial  pressure 
expressed  in  millimeters  of  mercury  <l<»es  not  t';ill  below  the  pulse-rate 
expressed  in  beats  per  minute,  the  fad  may  be  taken  as  of  excellenl  augury, 
while  the  converse  is  equally  true  (Gibson). 

Diseases  op  the  Nervous  System. — In  locomotor  ataxia  the  Light- 
ning-pains are  attended  by  a   fall   in  blood-pressure;   in   the  gastric  crises 


128  MEDICAL  DIAGNOSIS. 

the  pressure  is  greatly  increased.  Arteriosclerosis  of  the  cerebral  vessels 
may  exist  without  similar  changes  in  the  general  vascular  system  Blood- 
pressure  estimations  are  therefore  without  value  as  indicating  the  exist- 
ence of  intracranial  vascular  lesions.  When  there  is  reason  to  suspect 
their  presence,  increased  arterial  pressure  due  to  cardiac,  vascular,  or  renal 
causes  affords  important  data  for  prognosis  and  treatment.  With  high 
pressure  there  is  danger  of  hemorrhage,  with  low  pressure  danger  of  throm- 
bosis. Cerebral  hemorrhage  is  attended  by  marked  hypertension  which 
continues  to  rise  as  the  hemorrhage  increases,  and  remains  stationary  or 
falls  when  the  hemorrhage  ceases.  Tn  uraemic  coma  the  pressure  is  also 
greatly  increased. 

In  epilepsy,  owing  to  the  difficulty  of  making  observations  during  the 
attack,  there  is  some  uncertainty.  During  the  attack  there  is  said  to  be 
a  sudden  rise  in  the  blood-pressure,  followed  by  a  rapid  fall  to  normal  as 
the  paroxysm  ceases.  In  coma  following  an  attack  of  general  convulsions 
the  fact  that  in  epilepsy  the  blood-pressure  falls  while  in  ursemia  it  remains 
high  is  of  diagnostic  importance.  In  tic  douloureux  there  is  a  rise  of  pres- 
sure during  the  pain  proportionate  to  the  intensity  of  the  attack.  Insom- 
nia may  be  associated  with  increased  tension  on  the  one  hand  or  normal 
or  diminished  tension  on  the  other.  In  the  former  condition  the  pressure 
falls  during  sleep.  In  hysteria  and  neurasthenia  the  pressures  are  variable. 
Some  observers  have  observed  high  pressures  in  neurotic  and  excitable 
persons,  but  this  condition  is  not  constant. 

Mental  Diseases. — In  melancholia  the  pressure  is  abnormally  high 
and  shows  rises  and  falls  corresponding  to  the  intensity  of  the  mental  symp- 
toms.   In  mania,  on  the  other  hand,  the  pressure  tends  to  subnormal  levels. 

PERCUSSION. 

Percussion  in  physical  diagnosis  is  the  art  of  striking  or  tapping  upon 
the  surface  of  the  body  in  such  a  manner  as  to  call  forth  sounds,  from  the 
nature  of  which  conclusions  are  drawn  as  to  the  structure  of  the  underly- 
ing parts. 

This  art  was  first  described  and  systematically  employed  in  the  latter 
part  of  the  eighteenth  century  by  Auenbrugger,  a  physician  of  Gratz,  who 
published  his  observations  in  a  little  book  entitled  Inventum  Novum. 
The  subject  was  widely  brought  to  the  attention  of  the  profession  by 
Corvisart  in  the  beginning  of  the  following  century. 

The  practice  of  this  method  demands  nice  training  both  of  the  hands 
and  ear  in  order  to  secure  its  best  results.  Careless  and  inexact  methods 
yield  not  only  unsatisfactory  but  also  positively  misleading  results.  It  is 
especially  true  of  percussion  that  they  find  it  most  useful  who  most 
clearly  realize  its  limitations  as  an  art  in  diagnosis.  Unfortunately  too 
many  practitioners,  otherwise  well  trained,  fail  to  acquire  proficiency  in 
percussion  and  equally  fail  to  appreciate  its  limitations. 

Neither  percussion  nor  auscultation  requires  the  possession  of  much 
technical  knowledge  of  acoustics  nor  a  cultivated  musical  ear.  It  is,  how- 
ever, necessary  to  be  able  to  discriminate  differences  in  the  character, 
intensity,  and  pitch  of  sounds. 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  129 

The  Theory  of  Percussion. — Reduced  to  its  simplest  terms  the  theory 
of  percussion  depends  upon  the  differences  in  the  vibrations  produced  by 
blows  delivered  upon  structures  which  do  not  and  those  which  do  contain  air, 
and  in  the  latter  case  upon  differences  in  the  mechanical  arrangement  under 
which  the  air  is  present.  There  is  nothing  a  priori  in  the  matter.  Our 
whole  knowledge  in  regard  to  the  signs  elicited  is  the  result  of  observation 
and  experience.  It  has  been  found  that  direct  percussion,  that  is,  percus- 
sion without  the  intervention  of  a  finger  or  other  form  of  pleximeter,  prac- 
tised upon  the  thigh,  which  does  not  contain  air,  produces  a  minimum  of 
sound  which  has  a  peculiar  quality,  technically  described  as  dull.  The 
interposition  of  a  pleximeter  increases  the  intensity  of  the  sound  and 
slightly  alters  its  other  acoustic  properties.  From  this  we  infer  that  in 
percussion  the  vibrations  of  the  pleximeter  itself  constitute  a  certain  factor 
in  the  general  result.  It  has  further  been  found  that  percussion  over  the 
liver  and  spleen,  organs  which  do  not  contain  air,  produces  a  similar  dull 
sound,  but  that  the  quality  of  dulness  is  modified  according  to  the  force 
with  which  the  act  is  performed.  Upon  light  percussion  over  the  spleen 
or  centrally  over  the  liver  the  dulness  is  much  like  that  of  the  thigh,  but 
upon  powerful  percussion  over  these  organs  the  dull  sound  is  modified, 
the  quality  of  resonance  being  added.  This  fact  in  connection  with  others 
presently  to  be  mentioned  leads  us  to  infer  that  by  light  percussion 
a  limited  region  of  the  wall  of  the  body  is  set  into  vibration,  but  that  the 
area  is  extended  by  forcible  percussion,  so  that  the  sound  produced  partakes 
of  qualities  due  to  the  sound-producing  mechanism  of  adjacent  organs  or 
structures,  and  that  if  we  desire  to  obtain  the  percussion  phenomena  pecu- 
liar to  an  organ  we  must  content  ourselves  with  well-defined  but  light 
percussion  of  the  surface  overlying  the  viscus  immediately  in  question. 
Experience  amply  confirms  this  inference.  It  has  been  further  established 
that  percussion  over  the  distended  bladder  or  a  cyst,  or  any  considerable 
collection  of  fluid,  as  a  serofibrinous  or  purulent  pleural  effusion,  produces 
a  dull  sound,  and  that  there  are  degrees  in  the  dulness  just  as  we  find 
differences  upon  light  and  heavy  percussion  over  the  spleen  and  liver, 
the  sign  having  a  certain  quality  of  resonance  at  some  parts  of  the  border 
or  edge  of  the  effusion  and  wholly  lacking  resonance  over  the  mass  or 
base  of  the  effusion.  The  recognition  of  these  differences  led  to  the  very 
proper  employment  of  such  terms  as  relatively  dull,  dull,  and  absolutely 
dull  or  flat.  To  return  to  the  liver  and  the  flatness  upon  light  percus- 
sion and  t lie  development  of  some  degree  of  resonance  upon  forcible 
percussion  especially  near  the  borders  of  the  dull  area,  we  have  attrib- 
uted the  latter  to  the  vibrations  of  adjacent  organs.  Pursuing  our 
investigations  we  find  thai  as  we  proceed  in  lines  upwards  the  sign 
changes  somewhat  abruptly  from  dull  to  a  distinctly  resonant  sound,  hav- 
ing qualities  hereafter  to  be  pointed  out,  which,  with  modifications  of 
intensity  and  so  on,  but  not  of  quality,  is  everywhere  present  over  the 
chest  where  the  surface  or  periphery  of  the  lung  cornea  into  contact  with 
the  wall.  For  this  reason  the  percussion  sound  elicited  over  the  chest,  and 
having  the  peculiar  resonant  quality  spoken  of,  is  known  as  pulmonary 
resonance,  or  briefly  and  technically  as  clear.  Again,  when  we  extend  our 
percussion  in  lines  proceeding  downwards  from  the  liver,  we  pass,  under 
9 


130  MEDICAL  DIAGNOSIS, 

normal  circumstances,  quite  abruptly,  about  the  margin  of  the  ribs,  to  a 
region  which  yields  upon  percussion  a  note  of  high  resonance  having 
likewise  peculiar  qualities  of  its  own,  which,  because  of  its  being  produced 
by  a  mechanism  remotely  analogous  to  that  of  a  drum,  is  called  tympanitic. 
A  very  important  fact  in  connection  with  these  three  fundamental 
qualities  of  the  signs  elicited  upon  percussion,  namely,  dulness,  clearness, 
and  tympany,  is  this,  that  they  are  constantly  related  to  and  dependent 
upon  the  absence  or  presence  of  air  in  the  examined  structures  and  upon 
the  mode  of  arrangement  of  the  air  when  it  is  present.  The  constant 
correspondence  between  the  clinical  and  post-mortem  percussion  signs  and 
the  post-mortem  conditions  justifies  us  in  formulating  the  following  dicta: 
Upon  percussion: 

1.  Airless  viscera  and  hollow  viscera  distended  with  fluid  yield  dulness, 
flatness. 

2.  The  normal  lungs  contained  in  the  chest  under  conditions  of  normal 
tension  yield  a  clear  note. 

3.  Air  contained  in  hollow  viscera,  as  the  intestines,  the  walls  of  which 
are  not  tense,  yield  tympanitic  resonance. 

These  physical  signs — namely,  clearness,  dulness,  and  tympany — are 
normal.  The  percussion  sound  clearness  as  such  is  always  normal.  It 
cannot  be  elicited  anywhere  save  over  the  chest,  and  there  is  no  condition 
of  structures  other  than  the  lungs  by  which  the  physical  arrangement 
essential  to  its  production  can  be  brought  about.  With  dulness  and  tym- 
pany the  case  is  different.  The  modifications  or  absence  of  clear  or  pul- 
monary resonance  in  regions  normally  occupied  by  the  lungs  constitute 
morbid  physical  signs.  Dulness  in  regions  normally  clear  or  tympanitic 
and  the  extension  of  dulness  beyond  the  limits  of  airless  viscera  constitute 
morbid  physical  signs,  and  this  statement  is  also  true  of  the  presence  of 
tympany  in  regions  in  which  the  physical  conditions  essential  to  its 
production  do  not  normally  exist. 

The  foregoing  facts  also  warrant  the  following  statements: 
Upon  percussion: 

1.  There  is  no  difference  in  the  physical  signs  by  which  a  distinction  can 
be  made  between  an  airless  viscus  and  a  collection  of  fluid. 

2.  The  signs  do  not  enable  us  to  determine  the  line  of  contact  between 
two  airless  viscera  or  an  air-less  viscus  and  a  collection  of  fluid,  or  between 
collections  of  fluid  separated  by  a  membrane. 

Percussion  is  the  application  of  an  every-day  art  to  diagnosis  in  medi- 
cine. The  woodsman  taps  with  his  axe  upon  the  trunk  of  a  tree  to  learn 
whether  or  not  it  is  hollow,  the  gauger  upon  the  cask  with  his  mallet  to 
find  the  level  of  the  wine,  and  the  carpenter  with  his  hammer  upon  the 
plastered  wall  to  fix  the  position  of  a  stud  into  which  he  can  drive  his  nail. 

The  Technic  of  Percussion. — The  patient  may  be  examined  in  the 
recumbent,  sitting,  or  erect  posture.  The  outer  clothing  should  be  removed. 
The  air  contained  in  thick  garments  or  in  several  layers  of  clothing  seri- 
ously modifies  the  results  of  percussion.  A  single  under-garment  or  a 
towel  is  preferable  to  the  bare  skin.  The  limbs  should  be  symmetri- 
cally disposed  and  the  muscles  relaxed.  Errors  may  arise  from  forcible 
percussion  when  the  patient  is  resting  upon  a  feather  bed  or  very  elastic 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  131 

mattress.  In  general  terms  much  display  of  energy  on  the  part  of  the 
physician  is  to  be  avoided.  It  not  only  yields  misleading  results  but  it 
also  alarms  and  may  even  hurt  the  patient. 

Two  methods  are  employed,  immediate  or  direct,  and  mediate  or 
indirect  percussion. 

Immediate  or  Direct  Percussion. — The  blow  is  struck  directly  upon  the 
surface  with  the  palm  of  the  slightly  flexed  hand,  or  upon  the  clavicles  or 
sternum  with  the  tip  of  the  second  or  third  finger,  or  upon  the  abdomen 
with  the  dorsal  surface — nail — of  the  second  finger  flicked  off  from  the 
thumb  as  one  flicks  a  crumb.  The  first  two  of  these  methods  were 
originally  employed.     The  last  is  a  modern  refinement. 

With  the  Palm  of  the  Hand. — The  whole  hand  slightly  flexed  or  the 
palmar  surface  of  the  fingers  held  closely  together  may  be  employed.  The 
blow  is  delivered  chiefly  from  the  wrist,  very  slightly  from  the  elbow,  care 
being  taken  to  avoid  too  much  force  and  the  over-production  of  noise. 
This  method  is  available  for  a  rapid  preliminary  survey  and  class  demon- 
stration of  gross  differences  between  the  sides  of  the  chest,  or  the  upper 
and  lower  part  of  one  side,  especially  posteriorly.  It  cannot  often  be 
employed  satisfactorily  in  the  examination  of  the  abdomen.  The  objec- 
tions to  it  are  that  it  demands  too  much  force  and  that  the  vibrations 
caused  are  too  extensive.     It  lacks  the  nicety  of  good  clinical  work. 

Direct  finger  percussion  over  the  clavicles  and  sternum  is  often  prac- 
tised, but  is  here  mentioned  only  to  condemn  it  as  mostly  inexact,  often 
misleading,  and  at  best  yielding  results  obtained  much  more  satisfactorily 
by  other  methods.  The  results  are  unsatisfactory  because  of  the  elasticity 
and  extensive  vibrations  of  long  and  flat  bones.  The  resonance  produced  is 
that  of  an  elongated  or  very  large  pleximeter — so-called  bone  or  osteal  reso- 
nance, well  illustrated  upon  percussion,  in  the  same  manner,  of  the  head  with 
the  finger-tip.  As  there  is  no  intracranial  air,  it  is  evident  that  the  reso- 
nance is  due  to  the  vibrations  communicated  by  the  bone  to  the  external  air. 

Direct  Percussion  or  Finger- flicking.  —  In  this  procedure  the  skin 
should  be  bared.  Very  exact  and  satisfactory  results  may  be  obtained, 
especially  in  the  examination  of  circumscribed  regions  in  a  thin-walled 
abdomen.  It  is  by  far  the  most  satisfactory  method  of  mapping  out  the 
limits  of  the  splenic  dulness. 

Mediate  or  Indirect  Percussion  —  Pleximetry.  —  The  blow  is  delivered 
not  directly  upon  the  surface  of  the  body  but  upon  an  interposed  plate  or 
disk  of  ivory  or  hard  rubber— a  pleximeter,  literally,  measurer  of  the  blow. 
This  instrument  should  be  quite  flat  with  rounded  edges,  about  an  inch 
and  three-quarters  in  length  and  five-eighths  of  an  inch  in  width,  so  that  it 
may  be  closely  applied  to  the  surface  in  the  intercostal  spaces.  There 
should  be  at  each  end  a  little  flange  or  ear  by  which  it  is  held  in  position. 
The  percussing  instrument  or  hammer  is  called  a  plexor,  and  consists  of  a 
suitable  head  of  soft  rubber,  or  metal  tipped  with  soft  rubber,  and  a  light, 
stiff  handle.  The  plexor  of  Wintrich  has  a  handle  or  shaft  nearly  corre- 
sponding in  length  to  a  human  hand  from  the  wrist-joint  to  the  first  pha- 
langeal joint  and  a  head  corresponding  in  length  from  the  last  named  joint 
to  the  tips  of  the  fingers.  Instrumental  pleximetry  is  much  used  among 
European  physicians. 


132  MEDICAL  DIAGNOSIS. 

Finger  Pleximetry — Finger  Percussion. — This  method  is  almost 
exclusively  used  by  American  physicians.  A  finger  of  the  left  hand  is  used 
as  the  pleximeter  and  the  right  hand  as  the  plexor,  the  fingers  being  flexed 
as  nearly  as  possible  at  a  right  angle  at  the  first  phalangeal  joint  to  form 
the  head  of  the  hammer,  and  the  hand  from  this  joint  to  the  wrist  forming 
its  handle  or  shaft.  The  blow  is  delivered  from  the  wrist  and  not  from  the 
elbow,  and  the  head  of  the  plexor,  made  up  of  the  last  two  phalanges,  must 
fall  at  a  right  angle  upon  the  dorsum  of  the  middle  or  terminal  phalanx  of 
the  finger  used  as  the  pleximeter,  the  palmar  surface  of  which  is  closely 
applied  to  the  part  examined.  It  is  scarcely  necessary  to  add  that  in  left- 
handed  persons  the  fingers  of  the  right  hand  are  used  as  pleximeters  and 
the  left  hand  becomes  the  plexor. 

The  advantages  of  finger  percussion  are  (a)  that  the  soft  palmar  under- 
surface  of  the  pleximeter  can  be  closely  applied  to  the  part  to  be  examined 
and  the  danger  of  a  thin  layer  of  air  between  them  wholly  avoided;  (b) 
that  the  finger  used  as  a  pleximeter  is  also  a  palpating  finger  and  receives 
sensory  impressions  concerning  the  firmness  or  elasticity  of  the  underljdng 
part  which  supplement  the  auditory  impressions  caused  by  the  vibrations 
occasioned  by  the  blow;  (c)  that  the  pleximeter  is  composed  of  tissues 
corresponding  in  physical  composition  with  the  wall  of  the  body,  which  it 
protects  from  the  blow  without  the  interposition  of  an  instrument  of  wholly 
different  composition,  and  (d)  that  the  instruments  are  always  at  hand. 

Flicking  percussion  may  also  be  intermediate,  a  finger  of  the  left 
hand  being  used  as  the  pleximeter. 

Superficial  and  Deep  Percussion. — These  terms  indicate  in  general 
the'  degree  of  force  employed.  In  superficial  percussion  the  blow  is  light 
and  the  vibrations  are  limited  in  extent  and  depth.  This  method  is  essen- 
tial in  the  study  of  conditions  in  which  the  percussion  signs  involve  limited 
areas,  as  in  the  heart  and  spleen,  or  in  which  we  have  to  deal  with  thin 
wedges  of  tissues  yielding  different  signs  which  overlie  each  other,  as  the 
lung  surrounding  the  cardiac  ventricles,  or  dipping  down  between  the  wall 
of  the  chest  and  the  liver  or  the  wedge-shaped  anterior  lower  border  of  the 
liver  occasionally  seen.  Superficial  percussion  enables  us  to  determine 
the  nature  of  the  structure  immediately  beneath  the  surface,  and  is 
necessary  where,  by  reason  of  the  thinness  and  elasticity  of  the  walls, 
wide  areas  of  tissue  are  set  into  vibration  by  the  blow,  as  in  children 
and  emaciated  persons,  and  in  elderly  persons  whose  costal  cartilages 
have  undergone  calcification.  Only  superficial  percussion  should  be 
employed  in  the  examination  of  the  chest  after  recent  hemorrhage. 

Deep  percussion  excites  vibrations  in  wide  areas  and  to  a  considerable 
depth.  It  is  employed  where  the  chest  walls  are  very  muscular  or  fat  and 
to  ascertain  the  dulness  or  resonance  of  the  deeper  structures,  as  the  actual 
limits  of  cardiac  dulness,  the  upper  border  of  liver  dulness,  pneumonic 
consolidation  not  reaching  to  the  periphery  of  the  lung,  or  a  deep-seated 
aneurism.  In  the  case  of  a  wedge-shaped  anterior  lower  border  of  the 
liver  superficial  percussion  enables  us  to  demonstrate  the  actual  limits 
of  dulness,  while  deep  percussion,  by  acting  upon  the  underlying  intestine 
through  the  thin  wedge  of  liver,  yields  a  most  misleading  tympanitic 
resonance. 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  133 

The  following  directions  must  be  carefully  observed: 

1.  Apply  the  second  or  ring  finger  of  the  left  hand  accurately  and 
firmly  but  without  undue  pressure  to  the  surface  to  be  examined. 

2.  Raise  the  other  fingers  and  palm  from  the  surface  to  avoid  muffling 
the  vibrations.  The  finger  used  as  the  pleximeter  only  should  at  the 
moment  be  in  contact  with  the  surface. 

3.  Deliver  a  quick,  rebounding  blow,  with  the  tip  of  the  percussing 
finger  or  fingers  perpendicularly  upon  the  finger  used  as  a  pleximeter, 
upon  the  middle  phalanx  or  the  terminal  phalanx  above  the  nail.  The 
quicker  the  rebound  of  the  plexor  the  better  and  more  significant  the  result. 

4.  Let  the  blow  be  delivered  from  the  wrist  held  perfectly  loose  and 
not  from  the  elbow.  The  force  must  be  moderate  and  equal  at  correspond- 
ing points  upon  the  two  sides  of  the  chest;  lighter  where  the  chest  wall  is 
thin,  as  in  lean  persons  and  in  the  infraclavicular  and  axillary  and  infra- 
axillary  regions,  and  more  forcible  in  the  examination  of  the  back  of  a  very 
muscular  man  or  the  mammary  regions  of  one  who  is  fat. 

5.  The  attitude  of  the  patient  is  important.  It  must  be  easy  and 
unconstrained.  Rigid  and  fixed  positions  are  to  be  avoided.  Muscular 
tension  modifies  percussion  resonance.  The  arms  must  be  symmetrically 
arranged.  In  the  examination  of  the  anterior  surface  of  the  body  let  them 
lie  loosely  at  the  sides  in  the  recumbent  posture  or  hang  relaxed  if  the 
patient  is  erect;  in  the  examination  of  the  back  the  patient  should  bend 
forward  and  gently  fold  his  arms.  I  do  not  like  the  hands  to  be  placed 
each  upon  the  opposite  shoulder,  since  it  involves  an  undesirable  degree 
of  muscular  tension;  while  in  the  examination  of  the  lateral  regions  of  the 
chest  the  hands  should  be  placed  together  upon  the  top  of  the  head  with 
the  fingers  lightly  interlocked. 

6.  The  patient  must  breathe  gently  and  regularly.  If  changes  in  the 
percussion  signs  upon  full  held  inspiration  and  forced  expiration  are  to 
be  studied — respiratory  percussion — give  the  necessary  directions. 

7.  Perform  percussion  systematically  and  in  a  routine  manner,  exam- 
ining corresponding  parts  upon  the  two  sides  of  the  chest  above  and 
below,  anteriorly,  laterally,  and  posteriorly,  comparing  and  noting  the 
signs  at  each  step  in  the  proceeding.  Comparison  and  contrast  are  essential 
alike  in  percussion  and  auscultation.  It  is  often  useful  to  apply  two  or 
more  fingers  widely  separated  to  the  surface  and  lightly  percuss  one  after 
the  other.  In  this  way  the  border-line  between  dulness  and  clearness  or 
tympany  can  be  defined  ami  demonstrated  with  great  exactness. 

8.  Deliver  two  or  three  percussion  strokes  and  then  examine  the  cor- 
responding point  upon  the  opposite  side  in  the  same  manner.  This  ma- 
noeuvre maybe  repeated  as  often  as  is  necessary.  Dexterity  and  close 
attention  to  the  sounds  render  a  wearisome  prolongation  of  the  exami- 
nation  unnecessary. 

(.).  To  determine  the  borders  of  areas  of  dulness,  clearness,  or  tympany 
percuss  in  parallel  or  radiating  lines  and  note  the  points  in  such  lines  at 
which  the  quality  of  the  percussion  signs  changes.  Repeated  lighl  per- 
cussion is  often  necessary.  These  points  may  be  fixed  by  touches  with  the 
dermatographic  pencil,  which  when  joined  by  a  line  indicate  the  borders 
of  the   areas  studied. 


134  MEDICAL  DIAGNOSIS. 

Practitioners  gradually  develop  modifications  of  percussion  methods 
to  suit  themselves.  There  are  many  different  methods,  but  not  every  one 
of  them  is  right.  Those  not  based  upon  a  knowledge  of  the  principles  upon 
which  this  method  of  physical  diagnosis  rests  and  those  which  are  slovenly 
or  careless  are  positively  wrong.  It  is  like  playing  a  musical  instrument. 
Knowledge,  aptitude,  and  training  are  essential,  and  there  are  good  per- 
formers, poor  performers,  and  those  who  cannot  play  at  all. 

Sources  of  error  especially  to  be  avoided  are: 

1.  Failure  to  apply  the  pleximeter  accurately  to  the  surface.  A  thin 
stratum  of  air  modifies  the  result  and  may  render  it  wholly  misleading. 

2.  Applying  the  other  fingers  or  the  palm  of  the  hand  to  the  surface 
in  such  a  manner  as  to  dampen  the  vibrations  and  muffle  the  sound. 

3.  Awkwardness,  slowness,  and  the  use  of  too  much  force  in  deliver- 
ing the  blow.  These  may  all  be  readily  avoided  if  the  percussion  stroke 
is  from  the  wrist  as  a  centre  of  movement  rather  than  the  elbow. 

4.  A  false  attitude  on  the  part  of  the  patient.  Many  persons  on  being 
examined  assume  rigid  and  fixed  postures  with  the  muscles  in  tension  and 
the  arms  in  constrained  positions. 

5.  Too  much  clothing,  and  setting  the  air  contained  in  the  pillow,  bed, 
or  mattress  into  vibration  by  powerful  percussion. 

6.  A  want  of  system  in  conducting  the  examination.  More  errors 
arise  from  carelessness  than  from  ignorance. 

THE  SIGNS  ELICITED  UPON    PERCUSSION. 

The   sounds  differ   among  themselves,    as  already   seen,   as  follows: 

A.  Quality:    (1)  Clear,  (2)  dull,  and  (3)  tympanitic. 

A  structure  containing  no  air  yields  upon  percussion  a  minimum  of 
sound  due  to  vibrations  in  the  surrounding  air  and  is  said  to  be  completely 
dull  or  flat. 

Changes  in  such  a  structure  by  which  it  becomes  air-containing  or  the 
contiguity  of  air-containing  structures  modify  the  percussion  sign,  which 
acquires  resonance,  and  the  dulness  is  no  longer  flat  or  complete,  but  marked, 
and,  as  it  is  a  question  of  degree,  moderate  or  merely  slight  or  relative. 

The  physical  signs  by  which  these  modifications  of  flatness  are  brought 
to  pass  are  (a)  in  the  direction  of  the  conditions  which  underlie  tympany, 
namely,  collections  of  air  contained  in  spaces  the  walls  of  which  are  not 
too  tense,  'as,  for  example,  the  intestines;  and  (b)  in  the  direction  of  the 
arrangement  of  the  air  in  the  lung  under  normal  conditions  which  involve 
a  certain  tension  as  to  the  vesicles  and  as  to  the  whole  lung  within  the 
thorax — clearness. 

The  terms  used  to  designate  (a)  modifications  of  dulness  in  the  direc- 
tion of  tympany  are  slight  tympany,  dull  tympany,  moderate  tympany,  and 
tympany. 

Special  modifications  of  tympany  are  cracked-pot  resonance  and 
amphoric  resonance. 

Cracked-pot  Resonance:  the  Cracked-metal  Sound.  —  This  per- 
cussion sign  requires  for  its  development  a  rather  forcible  abrupt  stroke 
while  the  mouth  of  the  patient  is  open.     The  physical  condition  is  an  air- 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  135 

containing  cavity  communicating  freely  with  a  bronchus  and  sufficiently 
near  the  surface  of  the  chest  to  be  compressed  by  the  sudden  blow.  It 
may  also  be  elicited,  in  the  absence  of  cavity  formation,  in  conditions  in 
which  by  reason  of  yielding  chest  walls  a  certain  amount  of  air  contained 
in  the  lungs  or  in  the  pleural  cavity  is  suddenly  forced  by  strong  percussion 
into  the  large  bronchi.  We  may  encounter  the  cracked-pot  sound  therefore 
in  infants  not  suffering  from  disease  of  the  lungs,  especially  when  percus- 
sion is  performed  at  the  time  of  the  full  inspiration  of  crying,  in  pleurisy, 
above  the  level  of  an  effusion,  over  lung  relaxed  by  the  pressure  of  a  large 
pericardial  effusion,  sometimes  in  emphysema  and  in  certain  cases  of  pneu- 
mothorax. This  modification  of  tympanitic  resonance  may  be  imitated 
by  sharply  percussing  the  cheek  while  the  mouth  is  open  or  by  striking 
the  two  hands  held  together  against  the  knee  in  such  a  way  as  to  cause  a 
sound  like  that  produced  when  coins  are  rattled  in  the  hands.  For  this 
reason  the  cracked-pot  sound  is  sometimes  called  the  money-jingle  sound. 
This  sound  is  in  many  cases  only  to  be  heard  when  at  the  moment  of  per- 
cussion the  patient's  open  mouth  is  turned  directly  toward  the  ear  of  the 
physician  or  when  the  patient  holds  the  bell  piece  of  a  double  stethoscope 
just  in  front  of  his  open  mouth.  As  sudden  compression  of  the  cavity  is 
essential  the  blow  must  be  of  some  force  and  as  the  walls  of  such  a  cavity 
are  not  always  highly  resilient  the  peculiar  phenomenon  in  question  is  often 
produced  only  upon  the  first  two  or  three  strokes  of  percussion  and  suf- 
ficient time  must  elapse  for  the  full  redistention  of  the  cavity  before 
the  cracked-pot  sound  can  again  be  heard. 

Amphoric  or  Metallic  Resonance.  —  This  sign  has  the  quality 
characteristic  of  the  sound  produced  by  percussing  a  large  vessel  with  a 
wide  mouth — amphora,  a  jar.  It  is  a  ringing  tympanitic  sound  and  denotes 
a  cavity  of  considerable  size  with  firm  elastic  walls  which  do  not  vibrate 
in  unison.  The  pitch  varies  with  the  shape  and  size  of  the  cavity  and  the 
degree  of  tension  of  its  walls.  A  closed  cavity  distended  with  air  or  gas 
under  pressure  so  that  its  walls  vibrate  in  unison  yields  dulness  on  percus- 
sion. Amphoric  resonance  frequently  occurs  without  the  cracked-pot 
quality,  but  the  cracked-pot  sound  is  usually  also  amphoric. 

(b)  Modifications  of  dulness  in  the  direction  of  clearness  are  slight 
or  relative  dulness,  impaired  resonance,  clearness. 

But,  leaving  dulness  altogether  out  of  the  question,  we  find  that  changes 
in  the  physical  condition  in  the  lung  by  which  the  normal  or  vital  tension 
is  relaxed  frequently  occur.  This  takes  place,  for  example,  in  congestion. 
in  oedema  and  atelectasis  from  compression,  in  both  of  which  the  residual 
air  is  diminished,  and  the  normal,  clear  or  vesicular  resonance  acquires  the 
tympanitic  quality  to  a  varying  degree — vesiculotympanitic  resonance — 
and  as  the  lesions  upon  which  vesiculotympanitic  resonance  depends 
undergo  resolution  this  sign  is  gradually  replaced  by  the  normal  or  clear 
resonance  again.  These  changes  can  occur  only  in  regions  in  which  we 
normally  find  the  clear  or  vesicular  percussion  resonance,  namely,  over 
the  lungs.  It  has  been  demonstrated  experimentally  that  the  extreme 
distention  of  a  hollow  viscus,  as  a  bladder,  with  air  so  that  its  opposite 
walls  upon  percussion  do  not  vibrate  independently,  bul  as  a  whole  does 
away  with  the  tympanitic  sound,  and  causes  it  to  be  replaced  by  dulness. 


136  MEDICAL  DIAGNOSIS. 

B.  Volume  or  Intensity. — This  acoustic  property  is  of  minor  impor- 
tance in  percussion.  It  depends  upon  the  volume  of  air  contained  in  the 
structures  examined,  the  elasticity  of  the  enclosing  walls  and  energy  of 
their  vibrations,  and  the  force  of  the  blow.  This  term  has  reference  to  the 
loudness  or  degree  of  sonority  of  percussion  sounds,  which  may  be  on  the 
one  hand  so  great  as  to  obscure  their  value  or  on  the  other  so  faint  as  to 
be  without  any  significance  whatever.  The  duration  of  percussion  sounds 
usually  corresponds  to  their  volume  or  intensity. 

C.  Pitch. — The  distinction  between  sounds  and  musical  tones  must 
be  borne  in  mind.  In  percussion  we  have  to  do  with  the  former.  Never- 
theless the  pitch  of  percussion  sounds  is  of  great  importance.  Pitch  indi- 
cates in  music  the  relative  position  of  notes  upon  the  scale  and  depends 
upon  the  frequency  of  the  vibrations  by  which  tones  are  produced.  In 
physical  diagnosis  we  find  that  large  air-containing  spaces  with  slight  or 
moderate  tension  yield  percussion  resonance  of  low  pitch,  while  small 
spaces  with  high  tension  yield  resonance  of  higher  pitch,  and  that  the  vibra- 
tions of  the  pleximeter  upon  the  thigh  or  over  an  airless  viscus  yield  a 
sound  of  slight  intensity  and  high  pitch. 

Percussion  over  the  abdomen  reveals  great  variations  in  the  pitch 
of  sounds  having  the  quality  of  tympany,  as  over  the  stomach  and  large 
and  small  intestines.  These  variations  are  of  some  value,  but  cannot  be 
relied  upon  in  mapping  out  the  positions  of  those  viscera.  They  serve  a 
purpose  in  indicating  the  border-line  between  contiguous  organs,  as  the 
stomach  and  transverse  colon  and  coils  of  intestines  under  different  degrees 
of  tension. 

The  quality  of  a  sound  is  that  property  which  enables  us  to  recognize 
it  whenever  heard  without  seeing  the  mechanism  by  which  it  is  produced, 
as  the  sound  of  a  bell,  a  drum,  and  so  on;  the  volume  or  intensity  of  a 
sound  relates  to  the  energy  and  the  mass  of  the  material  by  which  it  is 
produced,  as,  for  example^  in  great  and  little  bells,  the  sound  of  which  has 
the  same  quality  and  may  have  the  same  pitch  while  differing  greatly  in 
intensity  or  volume;  the  pitch  depends  upon  the  rapidity  of  the  vibrations 
by  which  sound  is  produced,  as  in  the  long  strings  of  the  piano  which  pro- 
duce low  notes,  and  the  short  strings  which  send  forth  the  high  notes. 

The  Lung  Reflex  (Abrams).  —  It  has  been  observed  that  local 
irritation  of  the  skin  of  the  chest  as  by  cold  or  the  application  of  mustard 
has  been  followed  by  the  evidences  of  a  temporary  circumscribed  emphy- 
sema of  the  underlying  lung.  These  signs  of  dilatation  of  the  air-vesicles 
have  in  some  instances  been  confirmed  by  X-ray  examination.  Cabot 
has  referred  to  this  observation  in  explanation  of  the  fact,  well  known  to 
teachers  of  physical  diagnosis,  that  the  repeated  demonstration  of  an  area 
of  moderate  dulness,  as,  for  example,  in  incipient  tuberculosis,  is  followed 
by  a  modification  of  the  percussion  sign,  which  graduall}'  becomes  more 
resonant.  The  repeated  percussion  apparently  acts  as  a  local  irritant. 
If  the  consolidation  is  dense  and  extensive  this  change  cannot  occur. 

Respiratory  Percussion. — Differences  in  the  sound  are  noted  upon 
quiet  breathing  and  full  held  inspiration.  The  contrast  between  the  two 
sides  of  the  chest  in  slight  consolidation,  as  in  beginning  phthisis  or  pleural 
thickening,  is  thus  accentuated,  the  dulness  upon  the  affected  side  remain- 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  137 

ing  the  same,  while  the  resonance  upon  the  sound  side  is  increased.  This 
method  is  serviceable  in  determining  the  presence  or  absence  of  slight 
degrees  of  relative  dulness,  especially  in  the  infraclavicular  regions  in 
incipient  pulmonary  tuberculosis. 

Palpatory  Percussion. — As  has  been  pointed  out  in  the  general  con- 
sideration of  percussion,  palpation  is  an  essential  though  subordinate 
factor  in  finger  percussion,  which  is  gradually  taking  the  place  of  other 
methods.  Palpatory  percussion  is  a  method  in  which  the  attention  is 
especially  directed  to  the  resistance  and  elasticity  of  the  tissues  over  which 
the  percussion  is  performed.  It  consists  in  the  combined  use  of  palpation 
and  percussion  in  a  modified  form,  and  is  applicable  (a)  to  the  determina- 
tion of  the  outlines  and  boundaries  of  the  solid  viscera  under  various  con- 
ditions, but  especially  to  the  study  of  the  deep  dulness  of  the  heart  both 
when  the  lungs  are  normal  and  when  they  are  emphysematous;  (b)  to 
the  examinations  of  solid  organs  of  limited  size  surrounded  by  air-contain- 
ing and  resonant  structures,  as  the  spleen,  and  particularly  when  there  is 
tympanitic  distention  of  the  abdomen;  and  (c)  to  the  recognition  of  the 
extent  and  the  horizontal  levels  of  fluid  exudates  in  the  abdominal  and  tho- 
racic cavities  in  different  postures.  The  physical  signs  depend  to  a  greater 
extent  upon  the  sensation  of  resistance  imparted  to  the  percussion  finger 
than  upon  the  character  of  the  sounds  perceived,  though  both  have  value. 
Various  methods  have  been  described.  Delicacy  of  touch,  a  light  stroke, 
and  a  lingering  rather  than  a  momentary  contact  with  the  surface  under 
examination  are  essential  to  success  in  all  of  them. 

The  direct  methods  of  palpatory  percussion  are: 

1.  That  of  the  Writer. — This  consists  in  flicking  the  surface 
with  the  nail  of  the  middle  finger  in  the  manner  described  under  the 
caption  direct  or  immediate  percussion.  This  method  is  painless  to  the 
patient  and  yields  very  accurate  results.  The  nail  should  strike  the  surface 
percussed  flatly  and  linger  for  an  instant. 

2.  Maguibe's  Method. — The  palmar  cushion  of  the  tip  of  one  finger 
is  employed  as  the  plexor.  The  stroke  is  not  short  and  quick  but  prolonged 
and  combined  with  a  certain  movement  of  pressure  or  palpation. 

3.  Method  of  Hein. — The  first  and  middle  fingers  are  employed. 
the  tip  of  one  resting  upon  the  surface  while  the  other,  used  as  a  plexor, 
delivers  a  light  tap  upon  the  adjacent  surface,  palpation  and  percussion 
being  literally  performed  at  the  same  time.  The  fingers  are  alternately 
used  and  the  whole  surface  is  gradually  examined.  Very  accurate  results 
may  be  obtained  by  this   method. 

The  Indirect  Methods  Are :  1.  The  finger  used  as  a  plexiineter  is 
struck  lightly  with  the  fingers  of  the  other  hand,  which  are  slightly  flexed 
in  such  a  manner  that  the  blow  is  delivered  by  the  pulps  rather  than  the 
extreme  tips.  The  stroke  is  not  sharp  and  rebounding,  but  prolonged 
and  pushing,  the  so-called  palpating  stroke,  and  the  percussing  fingers 
remain  a  moment  upon  the  plexor  finger  before  the  blow  is  repeated. 

2.  That  of  Ebstein.  A  glass  pleximeter  4  centimetres  in  length  and 
1.3  centimetres  in  width,  with  a  projecting  bar  1.5  centimetres  in  height 
is  used.  This  is  held  firmly  in  place  while  the  finger  held  as  in  ordinary 
finger  percussion  delivers  a  gentle  but  pushing  or  pressing  percussion  stroke 


138  MEDICAL  DIAGNOSIS. 

upon  the  flat  upper  surface  of  the  bar.  The  pleximeter  devised  by  Sansom 
consists  of  a  slender  rod  of  square  section  having  at  one  end  attached  at 
right  angles  a  thin  plate  and  at  the  other  end  a  similar  plate  parallel  to 
the  first.  The  measurements  are  about  the  same  as  those  of  the  glass 
pleximeter  of  Ebstein,  but  all  the  parts  are  made  of  hard  rubber.  In  use 
the  larger  plate  is  applied  to  the  surface  of  the  chest  and  held  in  position 
by  the  tips  of  two  fingers,  one  on  each  side  of  the  rod.  Percussion  is  then 
made  upon  the  upper  plate,  the  finger  of  the  other  hand  being  employed 
as  a  plexor.  Greater  attention  is  paid  to  the  vibrations  perceived  by  the 
fingers  than  to  the  sound.  This  special  pleximeter  enables  the  observer 
who  has  acquired  skill  in  its  use  to  recognize  slight  modifications  of  the 
vibrations  produced  by  percussion  and  to  map  out  more  closely  than  by 
other  methods,  but  not  absolutely,  the  limits  of  the  deep  dulness  of  the 
heart  and  the  great  vessels. 

Auscultatory  Percussion. — The  binaural  stethoscope  is  applied  to  the 
surface  of  an  organ,  as  the  heart,  liver,  stomach,  etc.,  and  held  in  place  by 
an  assistant  or  the  patient  himself.  Using  finger  pleximetry  with  very  light 
strokes,  percussion  is  performed  in  radiating  lines  towards  or  away  from  the 
stethoscope  as  a  centre.  Direct  percussion  with  the  finger-tips  may  be  em- 
ployed in  case  the  observer  himself  is  obliged  to  use  one  hand  to  hold  the 
stethoscope  in  place,  or  a  light  stroking  touch  or  scratching  of  the  skin  will 
serve  the  purpose.  A  stiff  brush  or  the  handle  of  a  large  tuning-fork  in  vibra- 
tion may  be  used  for  this  purpose.  The  sounds  are  greatly  intensified  and 
changes  in  their  quality,  volume,  and  pitch  are  readily  appreciated.  Of 
especial  importance  are  the  abrupt  changes  that  take  place  as  the  line  of 
percussion  passes  over  the  border  of  the  organ  over  which  the  stethoscope 
is  placed.  The  points  at  which  the  change  occurs  being  marked  and  these 
points  being  joined  by  lines,  an  approximate  outline  of  the  organ  is  obtained. 
The  observation  must  be  controlled  and  errors  eliminated  by  percussing  in 
segments  of  widening  circles  and  by  the  employment  of  the  ordinary  methods 
of  percussion.  This  method  is  much  more  useful  in  the  examination  of  the 
abdominal  than  of  the  thoracic  viscera.  It  should  be  acquired  by  every 
student. 

Percussion  Signs  in  the  Chest. 

THE   EXAMINATION    OF   THE    NORMAL    CHEST    BY    PERCUSSION. 

Pulmonary  Resonance. — The  sounds  elicited  vary  in  different  regions. 
The  anterior  and  lateral  surfaces  are  more  resonant  than  the  posterior 
by  reason  of  the  greater  thickness  of  the  walls  of  the  last.  The  resonance 
in  the  former  is  known  as  normal,,  pulmonary,  or  vesicular.  The  portion  of 
the  apex  of  the  lung  above  the  clavicle  yields  a  sound  which  acquires  the 
tympanitic  quality — vesiculotympanitic — as  the  trachea  is  approached. 
Some  difficulty  in  the  application  of  the  finger  or  pleximeter  renders 
percussion  less  satisfactory  in  this  region  than  in  other  parts  of  the  chest. 
Over  the  clavicle  the  sound  has  the  peculiar  quality  known  as  osteal  reso- 
nance; is  dull  towards  the  scapular  extremity  and  acquires  a  distinctly 
tympanitic  quality  with  heightened  pitch  at  its  sternal  end  of  the  bone. 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  139 

In  the  infraclavicular  region,  that  is,  as  far  downward  as  the  fourth 
rib,  the  pulmonary  or  vesicular  resonance  is  characteristic.  There  is  usually, 
however,  a  slight  disparity  in  the  two  sides,  the  sound  of  the  right  being 
somewhat  less  resonant,  shorter  in  duration,  and  of  higher  pitch  than  the 
left.  The  recognition  of  this  fact  is  of  cardinal  importance.  From  the 
fourth  rib  downwards  on  the  right  side  the  resonance  upon  strong  per- 
cussion is  slightly  diminished,  owing  to  the  presence  of  the  dome  of 
the  right  lobe  of.  the  liver.  About  the  sixth  rib  the  pulmonary  reso- 
nance ceases.  During  full  inspiration  the  liver  is  pushed  downwards 
to  the  extent  of  an  inch  or  more  and  the  line  of  dulness  is  depressed 
to  a  corresponding  degree. 

On  the  left  side  the  vesicular  resonance  is  impaired  by  the  presence 
of  the  heart  between  the  fourth  and  sixth  ribs  and  to  the  left  as  far  as  the 
mamillary  or  midclavicular  line.  The  extent  of  this  area  is  diminished 
under  any  conditions  in  which  a  larger  wedge  of  the  border  of  the  lung  is 
interposed  between  the  wall  of  the  chest  and  the  heart,  as  upon  deep 
inspiration  and  in  those  who  have  deep  chests  and  voluminous  lungs.  At 
the  base  anteriorly  the  clear  resonance  passes  into  the  tympanitic  reso- 
nance of  the  fundus  of  the  stomach — Traube's  semilunar  space;  laterally 
into  the  dulness  of  the  spleen. 

In  the  lateral  regions,  axillary  and  infra-axillary,  percussion  yields 
vesicular  resonance  modified  in  the  direction  of  higher  pitch  and  dimin- 
ished intensity  towards  the  base  of  the  chest  by  the  presence  of  the  liver 
on  the  right  and  the  spleen  on  the  left  side. 

Posteriorly  the  sound  varies  markedly  according  to  the  region  per- 
cussed. The  greater  thickness  of  the  muscles  and  the  presence  of  the  scap- 
ula? are  to  be  considered.  The  resonance  is  everywhere  diminished  as 
compared  with  the  anterior  and  lateral  regions.  It  has  the  quality  of 
clearness  but  is  muffled  and  merges  into  dulness  over  the  scapula?.  The 
percussion  sound  is  clear  over  the  apices  but  usually  slightly  less  so  on 
the  right  side  than  on  the  left;  and  in  the  interscapular  regions,  which  are 
widened  when  the  patient  bends  forward  and  folds  his  arms.  It  is  also 
clear  from  the  angle  of  the  scapula  on  each  side  to  the  base  of  the  chest, 
namely,  about  the  level  of  the  tenth  rib,  where  on  the  right  side  the  liver 
dulness  begins.  On  the  left  side  the  clear  percussion  sound  may  be  found 
a  little  lower  than  upon  the  right;  while  the  resonance  upon  deep  percus- 
sion is  somewhat  diminished  on  the  right  by  the  convexity  of  the  liver 
and  on  the  left  to  a  less  extent  by  the  spleen. 

In  children  and  emaciated  persons  the  resonance  in  the  back  is  often 
very  good  and  percussion  yields  results  scarcely  less  satisfactory  than  in 
the  front   of  t  he  chest . 

Normal  Tympanitic  Areas  in  the  Chest. — These  are  at  the  sternal 
ends  of  the  clavicles,  over  the  manubrium  sterni  and  ;it  the  left  base  anteri- 
orly. The  first  and  second  of  these  regions  owe  their  tympanitic  resonance 
to  the  proximity  of  the  trachea  and  main  bronchi  and  their  osteal  quality 
to  the  large  proportion  of  bone  entering  into  the  wall  of  the  chest.  In 
elderly  persons  with  calcification  of  the  costal  cartilages  this  osteal  quality 
is  widely  present  and  when  combined  with  tympany  as  is  often  the  case 
greatly  impairs  the  value  of  the  percussion  signs. 


140 


MEDICAL  DIAGNOSIS. 


Manubrium 
stern  i. 


Percussion  directly  over  the  trachea  at  the  episternal  notch  and  that 
over  the  larynx,  i.e.,  over  the  plates  of  the  thyroid  cartilage,  yields  amphoric 
resonance.  The  normal  tympany  at  the  left  base  anteriorly  is  due  to 
the  presence  of  the  fundus  of  the  stomach  when  distended  with  air  and 
the  adjacent  transverse  colon.  The  curved  upper  border  of  this  space,  the 
convexity  of  which  corresponds  with  the  convexity  of  the  diaphragm,  is  of 
special  diagnostic  value.    The  degree  of  distention  of  the  stomach  increases 

this  curve,  which  is  flattened 
or  may  even  become  concave 
in  large  left-sided  pleural  effu- 
sions. Traube's  semilunar 
space  is  bounded  to  the  right 
by  the  left  lobe  of  the  liver 
— dull;  above  by  the  lung — 
clear;  to  the  left  by  the  spleen 
— dull  upon  light  percussion 
and  is  itself  tympanitic,  the 
tympany  being  continuous 
with  that  of  the  stomach  and 
transverse  colon.  It  often 
requires  nice  work  in  percus- 
sion to  map  out  the  border- 
line between  the  clear  vesic- 
ular resonance  which  forms 
the  upward  limit  of  this  space 
and  the  tympanitic  resonance 
of  the  space  itself. 

Dull  Areas  in  the  Nor- 
mal Chest. — These  are  found 
to  correspond  to  the  scapulae 
with  their  large  muscular 
masses  in  the  chest  wall,  the 
liver  and  spleen  reaching  up 
into  the  chest  in  the  vault  of 
the  diaphragm  and  the  heart  within  the  chest  itself.  The  scapular  dul- 
ness  has  already  been  described.  The  liver  dulness  extends  in  the  right 
midclavicular  line  from  about  the  sixth  rib  to  the  border  of  the  ribs  and 
shifts  downwards  an  inch  or  more  on  full  inspiration;  the  dulness  of  the 
left  lobe  is  continuous  vertically  with  the  cardiac  dulness,  from  which  it 
cannot  be  distinguished  by  ordinary  percussion,  although  the  border-line 
between  them  is  sufficiently  indicated  for  clinical  purposes  by  the  upper 
border  of  liver  dulness  on  the  right  side  and  the  position  of  the  cardiac 
impulse  on  the  left.  In  doubtful  cases  auscultatory  percussion  may  be 
employed.  The  heart  rests  upon  the  central  tendon  of  the  diaphragm  and 
the  upper  curvature  of  the  liver  fits  into  the  vault  of  the  diaphragm. 

The  area  of  the  splenic  dulness  extends  from  the  upper  border  of  the 
ninth  to  the  lower  border  of  the  eleventh  rib  and  from  a  point  slightly 
anterior  to  the  midaxillary  line  backward  towards  the  spine.  It  varies 
normally  with  the  physiological  changes  in  the  size  of  the  organ. 


Fig.  73. — Normal  tympany. 


PHYSICAL  DIAGNOSIS:     PERCUSSION  141 

Cardiac  Dulness. — The  cardiac  dulness  is  divided  into  the  superficial 
and  the  deep. 

Superficial. — The  superficial  cardiac  dulness  corresponds  to  that 
part  of  the  organ  constituted  by  the  anterior  surface  of  the  right  ventricle, 
which  uncovered  by  lung  lies  in  relation  with  the  chest  wall.  It  begins 
above  about  the  level  of  the  fourth  costal  cartilage  and  extends  to  the  apex, 
being  bounded  below  by  the  dulness  of  the  left  lobe  of  the  liver  and  on  the 
right  by  the  resonance  of  the  anterior  border  of  the  right  lung  at  the  middle 
line.  This  irregularly  quadrilateral  area  varies  in  size  according  to  the 
expansion  of  the  borders  of  the  lungs,  especially  the  left.  It  is  smaller 
upon  inspiration  than  upon  expiration  and  in  active  individuals  with  volu- 
minous lungs  than  in  sedentary  persons  with  small  and  narrow  chests.  It 
yields  upon  superficial  percussion  a  flat  and  upon  deep  percussion  a  dull  note. 

Deep. — The  deep  cardiac  dulness  corresponds  to  the  borders  of  the 
heart  itself  beneath  the  overlapping  margins  of  the  lung  and  extends  beyond 
the  area  of  superficial  dulness.  Upon  deep  percussion  over  this  area  the 
note  is  dull,  but  the  rounded  receding  surface  of  the  heart  renders  a  liter- 
ally exact  determination  of  its  limits  impracticable.  Even  the  most  skilful 
percussion  yields  onfy  approximate  results.  The  difficulties  in  determin- 
ing the  upper  and  right  border  of  the  heart  by  percussion  are  increased 
by  the  fact  that  the  organ  is  covered  in  those  regions  not  only  by  the 
borders  of  the  lung  but  also  by  the  sternum,  which  modifies  to  a  high  degree 
the  percussion  sound  of  the  structures  underlying  it. 

Enlargement  of  the  heart  gives  rise  to  increase  in  the  diameters  of 
both  these  areas,  the  deep  area  of  cardiac  dulness  being  increased  by  the 
enlargement  of  the  heart  itself;  the  superficial  area  by  the  pushing  aside 
of  the  margins  of  the  lungs.  The  determination  of  the  superficial  area  of 
cardiac  dulness  is  a  relatively  easy  matter,  but  the  knowledge  thus  obtained 
relates  rather  to  the  position  of  the  margins  of  the  lungs  than  to  the  size 
of  the  heart ;  the  determination  of  the  deep  area  in  so  far  as  it  is  practica- 
ble would  indicate  the  actual  size  of  the  heart,  but  the  difficulties  in  reach- 
ing exact  data  are  in  many  cases  insuperable.  For  these  reasons  we  cannot 
regard  percussion  as  the  best  method  of  ascertaining  the  size  of  the  heart. 
It  has  a  value  as  a  control  method,  but  the  position  of  the  apex-beat,  as 
determined  by  inspection,  palpation,  or  auscultation,  and  the  extent  of  the 
impulse,  with  associated  clinical  phenomena,  constitute  diagnostic  criteria 
at  once  more  convenient  of  application  and  far  more  precise. 

The  resonance  of  the  normal  chest  is  modified  within  narrow  limits 
by  a  variety  of  conditions,  among  the  more  important  of  which  are  the 
following: 

1.  Change  of  Posture. — In  the  lateral  decubitus  the  resonance  of  the 
lower  lung  is  slightly  less  than  that  of  the  upper  by  reason  of  the  greater 
amount  of  air  in  the  latter.  On  exchanging  the  recumbent  for  the  erect 
posture  the  pitch  of  the  percussion  sound  is  raised  (Da  Costa).  If  the 
patient  turns  upon  the  left  side,  the  heart,  under  the  influence  of  gravity, 
swings  outwards  towards  the  left  axilla,  with  a  corresponding  change  in 
the  position  of  the  apex  and  the  cardiac  dulness. 

2.  Respiration. — The  general  resonance  of  the  chest  is  greater  upon 
full  held  inspiration  than  on  quiet  breathing  simply  because  of  the  increase 


142  MEDICAL  DIAGNOSIS. 

of  air  within  its  cavity.  This  increase  of  resonance  may  be  noted  on  quiet 
respiration  after  great  muscular  exertion,  which  is  accompanied  by  a 
temporary  physiological  distention  of  the  vesicular  structure  of  the  lungs. 

The  increase  in  the  volume  of  the  lungs  upon  full  inspiration  not  only 
augments  the  resonance  but  also  extends  its  borders  in  certain  directions, 
especially  over  the  heart  so  that  the  superficial  area  of  cardiac  dulness  is 
diminished,  and  at  the  base  of  the  chest  so  that  the  liver  and  spleen  are 
carried  downwards  with  the  descending  diaphragm,  and  areas  at  the  base, 
dull  on  expiration  or  quiet  breathing,  yield  a  clear  note.  This  respiratory 
excursus  of  the  lower  margin  of  the  lungs  is  observed  posteriorly  as  well 
as  anteriorly,  but  not  to  the  same  extent.  It  varies  in  different  individuals 
in  health  just  as  the  inspiratory  expansion  varies  and  is  diminished  by  the 
presence  of  pleural  adhesions. 

3.  Gaseous  Distention  of  the  Stomach  and  Colon. — This  condition  may 
displace  the  upper  crescentic  convexity  of  Traube's  half-moon-shaped 
space  and  cause  tympanitic  resonance  in  the  lower  part  of  the  left  chest 
or  impart  a  tympanitic  quality  to  the  vesicular  resonance — vesiculo- 
tympanitic resonance.  It  may  also  to  some  extent  displace  the  diaphragm 
upwards,  thus  causing  the  lower  margins  of  the  lungs  to  assume  a  position 
slightly  higher  than  normal  with  a  corresponding  upward  displacement 
of  the  limit  of  pulmonary  resonance. 

Age. — In  children  the  lungs  are  relatively  small  and  the  dull  areas 
of  the  heart  and  liver  correspondingly  greater.  In  old  age  the  borders  of 
the  lungs  are  usually  emphysematous,  even  in  persons  otherwise  in  normal 
condition.  Hence  the  area  of  superficial  cardiac  dulness  is  encroached 
upon  and  the  upper  border  of  liver  dulness  is  slightly  lower  than  at  earlier 
periods  of  life.  Under  this  circumstance  the  vesicular  resonance  acquires 
a  faintly  tympanitic  quality. 

The  Condition  of  the  Chest  Wall. — The  obvious  part  in  this  respect 
played  by  great  muscular  development  and  obesity  has  already  been 
spoken  of.  There  are  persons  in  whom  percussion  on  account  of  these 
obstacles  yields  negative  results.  (Edema  of  the  chest  wall  is  also  an 
important  obstacle.  Highly  developed  mammae  likewise  interfere  with  the 
application  of  this  method  of  examination;  so  also  do  the  tenderness  of 
inflammation  of  the  chest  wall  and  hyperesthesia. 

PERCUSSION    IN    DISEASE   OF   THE   THORACIC   ORGANS. 

Percussion  in  the  different  regions  of  the  normal  thorax  yields  (1) 
vesicular  resonance,  the  sign  of  normal  lung  tissue  under  normal  intra- 
thoracic tension;  (2)  diminished  resonance  or  dulness  over  the  scapulae 
and  the  area  of  deep  cardiac  dulness;  (3)  absence  of  resonance  or  flatness 
over  the  lower  ribs  on  the  right  side  anteriorly;  (4)  vesiculotympanitic 
resonance  towards  the  base  of  the  chest  anteriorly  on  the  left;  (5)  tym- 
panitic resonance  over  Traube's  semi-space  and  over  the  manubrium  and 
the  sternal  ends  of  the  clavicles;  (6)  amphoric  resonance  over  the  trachea 
and  cracked-pot  resonance  sometimes  in  the  crying  infant.  While  these 
sounds  are  normal  when  obtained  in  the  particular  regions  of  the  chest 
above  indicated,  they  become  abnormal  or  morbid  signs  in  other  positions. 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  143 

Thus  vesicular  resonance  in  the  area  of  superficial  cardiac  dulness  may 
indicate  dextrocardia  or  some  other  form  of  malposition  of  the  heart; 
diminished  resonance  or  dulness  in  the  infraclavicular  or  mammary  regions 
may  be  significant  of  tuberculous  infiltration  or  at  the  bases  of  broncho- 
pneumonia; absence  of  resonance  or  flatness  over  a  large  area  on  either 
side  which  is  normally  clear  denotes  pleural  effusion,  a  tumor,  or  some  other 
airless  condition;  vesiculotympanitic  resonance  is  the  sign  of  a  moderate 
degree  of  atelectasis  due  to  compression  of  the  lung  and  of  emphysema; 
when  of  high  degree  it  constitutes  the  percussion  sign  known  as  skodaic 
resonance;  tympanitic  resonance  elsewhere  than  normal  is  the  sign  of  a 
cavity,  pneumothorax,  or  pneumopericardium;  and  amphoric  resonance 
save  over  the  trachea  and  the  cracked-pot  sound  except  in  crying  children 
must  in  all  instances  be  looked  upon  as  pathological  conditions. 

The  changes  which  modify  the  normal  resonance  affect  (a)  the  borders 
of  the  lungs;  (b)  the  structure  and  tension  of  the  lungs,  and  (c)  adjacent 
organs.     They  may  be  general,  unilateral,  or  local. 

Changes  in  the  Relation  of  the  Borders  of  the  Lung  to  the  Wall 
of  the  Thorax. 

The  Apices. — The  lungs  normally  reach  about  an  inch  and  a  half  to 
two  inches  above  the  clavicles,  the  right  apex  being  usually  somewhat 
higher  than  the  left.  Normal  pulmonary  resonance  is  obtained  therefore 
in  both  retroclavicular  spaces.  If  absent  in  one  or  both  and  especially 
when  replaced  by  dulness  there  is  consolidation  and  retraction  of  the  apex 
or  apices.  This  sign  is  significant  of  tuberculous  disease,  fibroid  phthisis,  or 
local  adhesive  pleurisy.  It  is  often  stated  that  bulging  of  the  retroclavicular 
space  with  tympanitic  resonance  occurs  in  emphysema.  This  is  not  always 
true.  Owing  to  the  skeletal  changes  in  the  thorax  in  emphysema  of  high 
grade  there  is  usually  retraction  of  the  spaces  immediately  above  and  below 
the  clavicles.  Transient  prominence  with  vesiculotympanitic  resonance 
occurs  in  the  acute  emphysema  of  asthma  and  pertussis. 

The  Anterior  Borders. — The  resonance  is  marked  by  the  osteal  quality 
of  the  percussion  sound  over  the  sternum  and  the  signs  are  uncertain. 
Below  the  level  of  the  fourth  costal  cartilage  the  border  of  the  left  lung 
sweeps  downward  and  to  the  left,  and  is  readily  made  out  by  percussion, 
forming  the  upper  and  left  lateral  boundary  of  the  area  of  superficial  cardiac 
dulness.  Below  the  clinical  apex  of  the  heart  and  between  the  anatomical 
apex  and  the  chest  wall  a  tongue-like  projection  of  the  anterior  border  of 
the  lower  lobe  called  the  lingula  gives  rise  to  a  clear  percussion  sound  over 
a  limited  wedge-shaped  space.  The  anterior  border  of  the  left  lung  is 
pushed  aside  by  an  hypertrophied  heart  or  large  pericardial  effusion  so 
that  the  area  of  superficial  cardiac  dulness  is  increased.  An  increase  in 
diameter  is,  however,  much  more  frequently  due  to  diminution  in  the 
volume  of  the  lung  as  in  tuberculous  or  fibroid  disease  and  consequent 
retraction  of  its  borders.  In  substantive  chronic  emphysema  and  the  acute 
emphysema  of  asthma  and  whooping-cough  the  left  border  of  the  lung  is 
advanced  and  in  extreme  cases  to  such  an  extent  as  to  obliterate  the  area 
of  superficial  cardiac  dulness. 

The  Lower  Borders. —  Due  allowance  must  he  made  for  the  changes 
caused  by  posture,  exertion,  age,  etc.   (p.   141  ).     The  borders  are  lowered 


144  MEDICAL  DIAGNOSIS. 

in  pathological  conditions  in  which  the  volume  of  the  lungs  is  increased 
and  they  occupy  a  position  higher  than  normal  when  it  is  diminished. 

In  advanced  cases  of  emphysema  the  lower  border  of  the  lung  as 
marked  by  the  transition  to  liver  dulness  on  the  right  side  and  to  tympany 
on  the  left,  may  reach  the  ninth  rib  and  a  corresponding  level  in  the  lateral 
and  posterior  regions.  The  respiratory  excursus  of  the  border  is  very 
limited  in  this  disease.  It  is  likewise  much  restricted  by  old  pleural 
adhesions.  Permanent  upward  displacement  with  restricted  respiratory 
movement  is  a  sign  of  tuberculous  or  fibroid  shrinking,  chronic  broncho- 
pneumonia, or  pulmonary  collapse.  The  lung  border  may  be  pushed  up 
by  a  distended  abdomen,  or  drawn  up  by  its  own  elasticity  in  paralysis  of 
the  diaphragm.  It  is  also  displaced  upward  and  rendered  immovable  by 
fluid  or  air  in  the  .pleural  cavity — hydro-pyo-haemo-pneumothorax. 

Impaired  Resonance;  Dulness;  Flatness. — The  resonance  is  dimin- 
ished in  proportion  as  the  amount  of  air  is  decreased  in  the  part  percussed. 
It  is  modified  according  to  the  changes  in  the  physical  structure  of  the 
spaces  containing  the  air  caused  by  the  lesions  of  disease.  Consolidation  of 
the  lung  from  exudate  within  its  substance,  compression,  infarct,  collapse, 
renders  the  percussion  sound  over  the  affected  area  less  resonant  in  pro- 
portion to  the  extent  of  the  lesion.  In  disseminated  lesions,  as  those  of  the 
common  forms  of  ordinary  or  tuberculous  bronchopneumonia,  there  is  usu- 
ally a  local  compensatory  emphysema  which  modifies  the  dulness.  The 
association  of  heightened  pitch  and  diminished  volume  with  diminished  pul- 
monary resonance  must  always  be  borne  in  mind.  In  many  instances  the 
well-trained  ear  will  recognize  a  change  in  the  pitch  of  the  percussion  sign 
before  alteration  in  its  quality.  The  sensation  of  increased  resistance — 
loss  of  elasticity— which  is  experienced  by  the  pleximeter  finger  in  fluid 
exudates  and  dense  consolidations  is  also  to  be  remembered. 

Impaired  resonance  is  a  sign  of  beginning  or  disseminated  tubercle, 
bronchopneumonia,  early  croupous  pneumonia,  small  effusions,  thickened 
pleura,  gangrene  of  limited  extent,  and  small  abscesses  or  tumors.  Dulness  is 
present  when  the  lesions  of  the  above  conditions  are  close  set  or  extended. 

Flatness  when  no  Air  is  Present. — The  percussion  sound  is  dull  over 
the  complete  consolidation  of  croupous  pneumonia  involving  a  lobe  or  an 
entire-  lung  because  some  air  yet  remains  in  the  large  and  middle-sized 
bronchial  tubes;  it  is  flat  over  a  large  effusion  because  the  lung  with  its 
compressed  vesicles  and  with  it  the  air-containing  bronchi  are  pushed 
wholly  away.  The  presence  of  circumscribed  consolidations,  especially 
when  not  directly  beneath  the  chest  wall,  cannot  be  recognized  by  percus- 
sion. Their  only  sign  may  be  a  slight  elevation  of  the  pitch.  Hence  central 
pneumonias  and  deep-seated  aneurisms  are  frequently  overlooked.  An 
effusion  into  the  pleura  of  serum,  pus,  or  blood  which  does  not  reach  500 
to  750  cubic  centimetres  in  volume  does  not  often  yield  definite  physical 
signs  upon  percussion,  and  a  pericardial  effusion  of  half  this  amount  may 
escape  detection.  In  pneumothorax  when  the  bronchopulmonary  fistula 
has  closed  and  the  air  is  present  under  a  high  degree  of  tension,  the  per- 
cussion note  over  the  greater  part  of  the  affected  side  may  be  dull. 

Impaired  resonance  over  the  apex  or  upper  lobe  of  one  lung  with 
normal  resonance  elsewhere  is  commonly  significant  of  tuberculosis.    It 


PHYSICAL  DIAGNOSIS:     PERCUSSION. 


145 


may,  however,  be  caused  by  an  apex  pneumonia  or  gangrene.  Dense 
pleural  thickening  is  also  a  cause  of  dulness  in  this  region.  Slight  impair- 
ment of  resonance  in  this  region  which  passes  away  upon  repeated  deep 
inspiration  or  prolonged  percussion  may  simply  indicate  habitual  deficient 
respiratory  expansion  of  the  lungs. 

Dulness  at  the  base  of  the  chest,  always  more  pronounced  and  signifi 
cant  posteriorly,  may  be  the  sign  of  pneumonia,  cedema,  hypostatic  con- 
gestion, atelectasis,  or  pleural  effusion  or  thickening.     Less  commonly  it 
stands  for  infarct,  abscess,  gangrene,  tuberculosis,  or  tumor. 


Fig.  74. — Pleural  effusion,  left  side,  showing  degree  of  displacement  of  heart  and  of  obliteration  ot 

Traube's  semilunar  space. 


Fig.  7oa. — Pneumohydrothorax — erect  posture. 


Fig.  756.— Pneumohydrothorax — dorsal  decubitus. 


Flattening  of  the  convexity  of  Traube's  semilunar  space  is  a  sign 
of  moderate  pleural  effusion  ;  marked  depression,  with  a  concave  upper 
line,   occurs    in    massive   effusion. 

Vesiculotympanitic  resonance  of  woodeny  quality  is  significant  of 
extensive  fibroid  changes  in  the  lung. 

Dulness  at  one  <>r  the  other  base,  the  upper  line  shifting  quickly  upon 
change  in  posture  is  characteristic  of  pneumohydrothorax.  The  upper 
line  of  small  pleural  effusions  shifts  much  more  slowly  and  that  of  large 
effusions  scarcely  at   all  save  in  prolonged  and  decided  change  of  posture. 

It  is  to  be  remembered  that  a  pleural  effusion  which  develops  insidiously 

while  the  patient   is  up  and  aboul   occupies  the  lower  part   of  the  chest   and 
causes  dulness  at  the  base  anteriorly,  while  one  that  accumulates  in  a  bed- 
10 


146  MEDICAL  DIAGNOSIS. 

ridden  patient  may  cause  extensive  dulness  posteriorly  and  reveal  itself 
anteriorly  merely  by  skodaic  resonance.  The  significance  of  dulness  in  the 
interscapular  region  is  often  obscure.  It  may  be  a  sign  of  pulmonary 
collapse  or  great  enlargement  of  the  bronchial  glands.  In  the  latter  case 
there  is  also  dulness  instead  of  osteal  tympany  over  the  lower  cervical 
vertebras.  Dulness  or  flatness  in  the  left  suprascapular  or  particularly 
in  the  left  interscapular  space  may  be  caused  by  the  presence  of  an  aneurism 
of  the  descending  aorta. 

Increased  Resonance — Hyperresonance — Vesiculotympanitic  Reso= 
nance — Tympany. — Solidification  of  lung  tissue  changes  its  percussion 
note  to  dulness.  An  increase  in  the  amount  of  air  causes  an  increase  of 
resonance,  but  does  not  necessarily  change  the  quality  of  the  note,  which 
retains  its  clearness  alike  in  shallow-chested  and  in  deep-chested  individ- 
uals and  in  forced  expiration  and  in  full  held  inspiration.  In  truth 
the  change  from  the  clear  to  the  tympanitic  percussion  note  very  fre- 
quently accompanies  a  reduction  in  the  amount  of  air  contained  in  the 
portion  of  the  lung  under  examination.  The  resonance  has  a  tympanitic 
quality  in  extreme  dilatation  of  the  air-cells,  as  emphysema,  in  deep  con- 
gestion, oedema,  the  pressure  atelectasis  overlying  an  effusion  or  adjacent 
to  a  tumor,  and  that  part  of  the  lung  which  is  the  seat  of  collateral  fluxion 
in  pneumonia;  it  maybe  exquisitely  tympanitic  in  any  of  these  conditions. 

Clearness  is  replaced  by  tympany  over  portions  of  the  lung  which  have 
broken  down  with  the  formation  of  cavities,  provided  that  the  cavities 
contain  air;  when  they  are  filled  with  fluid  the  percussion  sound  is  dull. 

The  note  is  tympanitic  in  pneumothorax  and  in  the  rare  instances  of 
pneumopericardium  that  occur.  But  when  the  cavity  in  pneumothorax 
is  closed  and  the  air  is  present  under  high  tension  the  note  becomes  dull. 

The  tympanitic  percussion  sound  may  be  due  to  extrapulmonary 
conditions.  We  have  seen  that  percussion  of  the  parts  immediately  over 
the  trachea  and  main  bronchi  yields  resonance  having  this  quality.  In  the 
same  manner  inexpert  percussion  over  a  consolidated  lung  may  yield  a 
tympanitic  sound  due  to  the  air  in  the  trachea  and  large  bronchi  on  the 
one  hand  or  to  the  air  in  the  stomach  and  intestines  on  the  other. 

Finally,  the  bases  of  the  chest  posteriorly  in  crying  infants  in  health 
often  yield  a  tympanitic  sound,  and  that  sound,  as  has  been  pointed  out, 
sometimes  has  the  cracked-pot  quality. 

When  we  come  to  review  the  physical  conditions  present  under  the 
foregoing  circumstances,  we  are  impressed  with  the  fact  that,  whether 
directly  or  by  conduction,  the  vibrations  produced  by  percussion  act  upon 
air-containing  structures  which  do  not  fulfil  the  requirements  of  the  clear 
percussion  sound,  namely,  air  contained  in  elastic  vesicles  under  physio- 
logical tension  within  the  chest.  On  the  contrary,  they  present,  completely 
or  in  a  modified  manner,  the  very  conditions  necessary  to  the  tympanitic 
percussion  sound,  namely,  air  in  spaces,  the  walls  of  which  are  not  under 
any  great  degree  of  tension. 

In  emphysema  we  recognize  as  an  essential  lesion  that  nutritive  change 
in  the  alveolar  walls  which  interferes  with  expiratory  contraction;  even 
in  local  or  compensatory  emphysema  there  is  some  degree  of  impairment 
of  contractility  from  vesicular  overdistention.      In  congestion  and  oedema 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  147 

the  volume  of  air  in  the  chest  is  decreased  as  the  quantity  of  blood  is 
increased  or  serum  is  present  and  the  normal  tension  diminished  to  a  corre- 
sponding degree.  In  compression  of  the  lung  the  air  is  squeezed  out  of  the 
atelectic  portion  as  the  water  out  of  a  sponge  and  the  vesicular  tension 
is  done  away  with  altogether.  In  collateral  fluxion  the  condition  is  the 
same  as  in  congestion  from  other  causes.  In  the  foregoing  conditions  the 
percussion  sound  varies  from  vesiculotympanitic  resonance — mere  hyper- 
resonance — to  an  exquisite  tympany.  In  air-containing  cavities  within 
the  lungs  or  in  the  pleural  space  and  in  the  case  of  the  tracheobronchial 
or  gastro-intestinal  tympanitic  sound  we  have  to  do  with  the  conditions 
essential  to  this  phenomenon  and  the  quality  is  unmixed  and  constant. 

The  pitch  of  the  tympanitic  sound  varies  with  the  degree  of  tension 
of  the  air  within  the  cavity,  becoming  higher — dull  tympany — as  the 
tension  increases,  and  with  the  relative  width  of  the  opening  with  which 
the  cavity  communicates  with  the  air,  the  wider  the  opening  the  higher 
the  pitch.  The  student  may  demonstrate  these  facts  by  percussing  his 
distended  cheeks  under  progressive  degrees  of  tension  with  his  mouth 
closed  and  with  his  mouth  opened  progressively  to  the  full  extent. 

1.  Vesiculotympanitic  resonance  on  both  sides  of  the  chest  is  signifi- 
cant of  emphysema,  which  may  be  acute  as  in  asthma  or  pertussis,  or  chronic 
as  in  pseudohypertrophic  emphysema.  The  degree  of  tympany  varies  with 
the  grade  of  the  disease.  In  extreme  cases  the  percussion  sound  becomes 
high  in  pitch,  small  in  volume,  and  short  in  duration — dull  tympany. 

2.  The  percussion  note  is  hyperresonant  and  has  the  tympanitic 
quality  over  the  sound  side  in  the  vicarious  respiration  such  as  occurs  in 
extensive  disease  of  the  lung,  massive  pleural  effusion,  or  large  tumor  of 
the  opposite  side. 

3.  An  exquisite  tympanitic  sound,  often  partaking  of  the  amphoric 
quality,  is  present  over  the  affected  side  in  pneumothorax.  With  extreme 
intrapleural  tension  the  sound  becomes  less  resonant — dull  tympany  <>r 
flat  tympany — or  may  become  quite  dull. 

4.  Local  tympanitic  percussion  resonance  is  a  constant  sign  of  pressure 
atelectasis.  It  is  present  at  the  level  of  pleural  effusions,  above  towards 
the  axilla  and  at  the  base  posteriorly  on  the  left  side  in  massive  pericardial 
effusions,  and  surrounds  the  dulness  caused  by  pleural  and  pulmonary 
tumors.  In  old  cases,  as  the  atelectasis  becomes  complete,  the  tympanitic 
resonance  is  replaced  by  dulness. 

5.  Tympanitic  resonance  in  one  or  both  infraclavicular  spaces  a--<>- 
ciated  with  dulness  at  the  base  of  the  chest  may  be  a  sign  of  pleural  effusion, 
pneumonia  of  the  lower  lobe,  infarct,  abscess,  gangrene,  or,  especially  when 
bilateral,  of  oedema. 

6.  Tympanitic  resonance  at  the  sternoclavicular  articulation  and 
below  it  with  dulness  at  the  apex  is  usually  conducted  tracheobronchial 
resonance.     It  is  encountered  in  tuberculosis  and  apex-pneumonia. 

7.  Circumscribed  tympanitic  percussion  resonance  is  the  sign  of  a 
cavity  which  may  he  tuberculous,  bronchiectatic,  or  the  result  of  abe 

or  gangrene.  The  nearer  the  cavity  lies  to  the  surface  the  better  defined 
the  tympany.  Consolidation  of  the  intervening  lung  tissue  acts  in  the  sa  me 
way.     In  tuberculosis  a   cluster  of  small  communicating  cavities  is  often 


148  MEDICAL  DIAGNOSIS. 

present  at  the  apex.  Single  small  cavities  even  when  they  are  superficial, 
and  deeply  seated  cavities  even  when  of  moderate  size,  do  not  yield  a 
tympanitic  percussion  sound. 

8.  Subdiaphragmatic  tympanitic  resonance  when  the  distention  is 
extreme  may  be  elicited  by  percussion  in  the  anterior  axillary  line  on  the 
left  side  as  high  as  the  third  interspace. 

Amphoric  Resonance. — This  is  the  sign  of  a  cavity  of  large  size  or, 
when  very  extensive,  of  pneumothorax.  The  cracked-pot  sound  is  usually 
the  sign  of  a  cavity  of  some  size  with  compressible  walls  and  communicat- 
ing freely  with  a  bronchus.  The  essential  physical  requirement  is  that  the 
walls  should  be  freely  compressible  so  that  there  may  be  a  free  outrush  of 
air  at  the  moment  of  the  percussion  stroke. 

The  following  percussion  phenomena  described  in  the  text-books  are 
of  greater  clinical  interest  than  practical  value.  They  are  very  rarely 
brought  out  in  a  manner  that  amounts  to  a  demonstration. 

1.  Wixtrich's  Sign. — The  tympanitic  percussion  sound  is  higher 
in  pitch  upon  opening  the  mouth  and  lower,  when  it  is  closed.  The  patient 
should  open  his  mouth,  protrude  his  tongue,  and  breathe  quietly.  This 
phenomenon  is  occasionally,  but  by  no  means  in  the  majority  of  instances, 
observed  in  large  cavities  of  the  lung  or  pneumothorax  with  wide  com- 
munication with  a  bronchus. 

2.  Interrupted  Wixtrich's  Sigx. — If  the  foregoing  sign  is  exclu- 
sively present  in  the  sitting  posture,  it  is  evidence  of  a  cavity  containing 
fluid  which  in  one  posture  occludes  and  in  the  other  leaves  open  the  com- 
munication with  the  bronchus.  Under  these  circumstances  gurgling  or 
the  rale  of  cavities  is  usually  present. 

3.  Gerhardt's  Sign.  —  The  pitch  changes  with  change  of  posture, 
usually  becoming  higher  in  the  erect  posture  but  scarcely  ever  becoming 
higher  in  the  recumbent  position.  The  alterations  in  pitch  are  attributed 
to  the  changes  in  .the  sha'pe  of  the  cavity  caused  by  the  gravitation  of  the 
fluid  to  its  lowest  part. 

4.  Friedreich's  Sign. — The  tympanitic  resonance  over  a  cavity 
communicating  with  a  bronchus  is  higher  in  pitch  upon  inspiration  than 
upon  expiration.  The  change  in  pitch  is  always  slight  and  often  too  slight 
to  be  of  value  in  diagnosis.  The  inspiratory  rise  is  attributed  to  the  widely 
open  glottis  and  the  increased  tension  of  the  air  in  the  cavity. 

5.  Biermer's  Sign.  —  In  pneumohydrothorax  the  tympanitic  per- 
cussion note  is  lower  in  the  recumbent  than  the  erect  posture,  the  change 
being  clue  to  alterations  in  the  shape  and  relative  diameters  of  the  air 
space  caused  by  the  gravitation  of  the  fluid.  The  underlying  principle  in 
Gerhardt's  sign  and  Biermer's  sign  is  the  same. 

Coin  Percussion— Coin  Test— Anvil  Test. — Auscultation  is  performed  upon 
the  chest  while  an  assistant  percusses  at  a  point  diametrically  opposite 
upon  the  front  or  back  as  the  case  may  be,  using  a  coin  laid  flat  upon 
the  surface  as  a  pleximeter  and  another  as  the  plexor,  striking  with  its 
edge.  The  coins  should  be  of  some  weight,  as  fifty-cent  pieces  or  silver 
dollars.  If  pneumothorax  be  present  the  peculiar  auscultatory  sign  consists 
of  a  clear  metallic,  ringing,  bell-like  note.  Control  observations  may  be 
made  upon  the  opposite  side  and  over  the  compressed  lung.  This  sign 
does  not  occur  over  very  large  cavities — vomica. 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  149 

PERCUSSION    IN    DISEASE   OF   THE    HEART. 

The  normal  superficial  and  deep  cardiac  dulness  and  the  method  of 
determining  them  have  been  discussed  in  a  foregoing  section.  By  this 
method  of  physical  diagnosis  we  ascertain  approximately  the  size,  shape. 
and  position  of  the  heart,  the  relation  of  the  anterior  borders  of  the  lungs, 
especially  upon  the  left  side,  to  it.  and  the  presence  of  pericardial  effusion 
when  it  is  of  sufficient  amount.  The  area  of  superficial  cardiac  dulness  is 
ascertained  by  light  percussion  in  the  parasternal  line  from  above  down- 
wards until  dulness  with  a  distinct  sense  of  resistance  is  reached,  usually 
about  the  level  of  the  fourth  rib  or  its  lower  border.  This  point  is  in  a 
transverse  or  oblique  line  extending  downward  and  outward  from  mid- 
sternum.  Next  percuss  over  the  lung  upon  the  right  side  about  the  level 
of  the  fifth  rib  and  in  a  transverse  line  across  the  sternum  to  the  left.  About 
or  just  beyond  the  middle  line  the  sound  again  becomes  dull  and  the  resist- 
ance increased.  This  marks  the  limit  of  the  anterior  border  of  the  right 
lung.  Continuing  to  percuss  in  the  same  line  and  lightly  as  before,  we  reach 
a  point  at  which  the  sound  again  becomes  clear  and  which  corresponds  to 
the  anterior  border  of  the  left  lung  at  the  level  named.  This  determines 
the  transverse  diameter  of  the  superficial  area  of  cardiac  dulness.  The 
left  lower  angle  corresponds  to  the  apex  and  can  be  determined  by  palpa- 
tion. The  lower  border  is  bounded  by  a  line  prolonged  from  the  upper 
border  of  liver  dulness  to  the  apex  of  the  heart. 

The  area  of  deep  cardiac  dulness  may  be  roughly  estimated  by  per- 
cussion in  corresponding  parallel  lines  from  the  parasternal  line  on  the  right 
side  across  the  chest  to  the  left  and  from  above  downward  upon  the  left 
side  along  the  sternal  border,  the  parasternal  line  and  the  mamillary  line. 
The  base  line  is  the  same  in  both  areas.  The  first  modification  of  clear 
pulmonary  resonance  as  we  approach  the  heart  may  be  accepted  as  a  sign 
indicating  the  outline  of  that  organ. 

SIGNIFICANCE   OF    VARIATIONS    IN   THE    CARDIAC    DULNESS. 

Alterations  in  the  size  of  the  superficial  area,  as  has  been  heretofore 
stated,  are  usually  signs  of  pulmonary  rather  than  of  cardiac  disease.  They 
correspond  to  increase  as  in  emphysema,  or  decrease  as  in  phthisis  in  the 
volume  of  the  lung.  This  area  together  with  the  deep  area  undergoes 
changes,  however,  with  changes  in  the  volume  of  the  heart. 

Increase  of  Cardiac  Dulness. — When  the  enlargement,  as  determined 
by  percussion  and  Ol  her  met  hods,  extends  chiefly  to  the  left  and  downward, 
the  longest  diameter  being  oblique  from  above  downward  and  to  the  left, 
it  is  the  sign  of  hypertrophy  and  dilatation  of  the  left  ventricle.  When 
t  he  enlargement  i.  to  t  he  right ,  wit  h  ;tn  extension  of  t  he  dulness  in  t  he  t  hird 
and    fourth    intercostal    spaces   :it    the    righl    border   of   the   sternum   and    a 

rounded  blunt  apex,  the  longest  diameter  being  transverse,  it  is  a  sign  of 
hypertrophy  and  dilatation  of  the  righl  ventricle  and  auricle.  Enlarge- 
ment both  to  left  and  righl  indicates  hypertrophy  and  dilatation  of  both 

ventricles,    the   dilatation    under   these   circumstances   being  almost    always 

in  excess  of  the  hypertrophy. 


150  MEDICAL  DIAGNOSIS. 

Enlargement  of  the  boundaries  of  precordial  dulness  to  the  leit,  right, 
and  upwards  may  indicate  the  presence  of  a  pericardial  effusion.  The 
dulness  is  marked  and  its  outline  is  pyramidal  or  pear-shaped,  the  smaller 
end  being  directed  upward.  The  increase  in  dulness  may  be  first  observed 
in  the  angle  formed  by  the  right  border  of  the  cardiac  and  the  upper  border 
of  the  liver  dulness,  which  becomes  at  first  rounded  and  then  obliterated. 
The  dulness  may  extend  to  the  second  interspace  or  higher  and  is  sharply 
defined  at  its  borders.  In  pericardial  effusions  of  considerable  size  the 
compressed  left  lung  yields  a  vesiculotympanitic  or  tympanitic  resonance 
— dull  tympany;  skodaic  resonance.  The  apex-beat  may  be  felt  or  located 
by  the  intensity  of  the  first  sound  within  the  borders  of  dulness.  Percus- 
sion alone  will  not  always  enable  us  to  make  a  differential  diagnosis  between 
a  moderate  pericardial  effusion  and  extreme  dilatation  of  the  heart. 

Under  normal  conditions  the  impairment  of  resonance  due  to  the 
presence  of  the  aorta  and  pulmonary  artery  does  not  extend  beyond  the 
manubrium  on  either  side.  When  it  can  be  made  out  upon  the  right  side 
in  the  first  and  second  interspaces,  or  in  the  notch  of  the  sternum,  it  is 
usually  a  sign  of  dilatation  of  the  aorta  or  of  aneurism  of  the  ascending  or 
transverse  portion  of  the  arch.  Sometimes  it  indicates  the  presence  of  a 
mediastinal  tumor. 

Decrease  in  the  area  of  cardiac  dulness  is  mostly  caused  by  pul- 
monary emphysema,  by  which  the  heart  is  covered  more  completely  by 
the  lung  and  displaced  towards  the  middle  of  the  thorax.  The  heart  like 
other  muscle  masses  undergoes  atrophic  changes  in  acute  and  chronic 
wasting  diseases,  as  enteric  fever  and  consumption,  with  a  corresponding 
diminution  in  the  area  of  cardiac  dulness.  This  area  is  diminished  in  extent, 
altered  in  outline,  and  in  extreme  cases  rendered  wholly  unrecognizable 
by  percussion  in  left  pneumothorax,  pneumopericardium,  and  emphysema 
of  the  mediastinum,  such  as  follows  trauma  and  occasionally  occurs  in  fatal 
cases  of  pertussis  or  after  tracheotomy.  Extreme  meteorism  and  great 
distention  of  the  stomach  by  gas  may  cause  like  effects.  Under  these 
conditions  the  modified  pulmonary  resonance  of  the  deep  area  and  the 
dulness  of  the  superficial  area  are  replaced  by  a  tympanitic  note. 

Dislocation  of  the  Cardiac  Dulness. — The  heart  is  a  very  movable 
organ.  The  shifting  which  the  apex  undergoes  upon  changes  of  the  posture 
of  the  body  has  already  been  described.  The  heart  is  displaced  upwards 
by  great  meteorism,  ascites,  a  massive  abdominal  tumor,  or  pregnancy; 
to  the  left  by  pleural  effusion,  pneumothorax,  or  tumor  on  the  right  side; 
to  the  right  by  similar  conditions  upon  the  left  side.  Great  enlargement 
of  the  right  lobe  of  the  liver  likewise  displaces  the  heart  to  the  left.  Con- 
traction of  the  lung  with  adherent  pleurisy  displaces  the  heart  by  traction 
toward  the  affected  side,  as  in  old  pleural  effusions  that  have  undergone 
resorption  or  been  relieved  by  operation,  and  in  cirrhosis  of  the  lung. 
Aneurismal  or  cancerous  tumors  and  diaphragmatic  hernia  are  among  the 
rarer  causes  of  displacement  of  the  heart.  Practically  speaking,  displace- 
ments of  the  heart  are  the  result  of  diseases  of  the  pleura  or  lungs. 
The  greater  part  of  the  heart  and  its  apex  may  lie  to  the  right  of  the  median 
line  with  or  without  general  transposition  of  the  viscera.  Under  all  these 
conditions  except  the  last,  there  are  such  modifications  of  the  percussion 


PHYSICAL  DIAGNOSIS:     PERCUSSION.  151 

signs  relating  to  the  heart  as  to  render  that  method  of  physical  diagnosis 
still  more  unsatisfactory  and  frequently  wholly  useless  in  determining  the 
boundaries  of  the  cardiac  dulness,  valuable  as  it  remains  in  the  diagnosis 
of  the  primary  disease.  The  position  of  the  apex  as  located  by  palpation 
and  auscultation  constitutes  the  most  reliable  evidence  of  the  region  occu- 
pied by  the  displaced  heart.  The  diagnosis  of  congenital  displacement  of 
the  heart  should  in  no  instance  be  made  until  all  other  causes  capable  of 
producing  such  displacement  have  been  shown  to  be  absent. 

Percussion  in  the  Examination  of  the  Abdomen. 

This  method  is  far  less  valuable  than  palpation  in  the  diagnosis  of 
abdominal  diseases.  It  has,  however,  much  usefulness  for  direct  examina- 
tion and  is  particularly  important  in  controlling  the  results  obtained  by 
the  other  methods  of  physical  examination. 

The  Technic. — The  general  directions  are  the  same  as  in  the  technic 
of  palpation.  Direct  percussion  except  flicking  percussion  cannot  be 
employed,  owing  to  the  sensitiveness  of  the  surface  and  the  elasticity  of 
the  walls  of  the  abdomen.  As  in  palpation  the  patient  must  be  examined 
in  various  postures,  and  it  is  frequently  necessary  to  distend  the  stomach 
or  colon  with  air  or  water.  Auscultatory  percussion  is  of  service  in  deter- 
mining the  boundary  lines  between  contiguous  viscera,  whether  they  be 
solid  or  air  containing. 

PERCUSSION   OF   THE   ABDOMEN    IN    HEALTH. 

The  upper  limits  of  hepatic  and  splenic  dulness  are  determined  by 
vesicular  resonance.  With  this  exception  the  signs  relate  to  dulness  and 
tympanitic  resonance  and  their  modifications. 

The  normal  dull  areas  in  the  abdomen  are: 

(a)  Hepatic.  The  upper  border  of  dulness  begins  about  the  level  of 
the  sixth  rib  in  the  midclavicular  line.  Its  lower  border  nearly  corre- 
sponds with  the  arch  of  the  ribs.  This  area  of  dulness  shifts  with  the 
respiratory  movements  about  two  fingers'  breadth  on  quiet  and  slightly 
more  upon  deep  breathing.  The  dulness  extends  upon  corresponding 
lines  in  the  epigastric  zone  and  its  respiratory  excursus  is  less  at  the 
b;t<k  than  in  front.  The  dulness  of  the  left  lobe  extends  to  the  left  of 
the  median  line  and  is  continuous  vertically  with  that  of  the  heart. 

(b)  Splenic. — The  dull  area  of  the  spleen  occupies  the  space  between 
the  ninth  and  eleventh  ribs,  its  anterior  border  being  slightly  in  advance 
of  the  midaxillary  line.  Its  respiratory  excursus  is  slightly  less  than  that 
of  the  liver.     The  observation  must  in  all  cases  he  confirmed  by  palpation. 

The  above  are  constant  in  health. 

Dull  areas  thai  are  not  constant  also  occur  under  physiological 
conditions.     These  are: 

(c)  The  Distended  Bladder.  The  dull  area  is  situated  in  the  supra- 
pubic region  in  the  median  line.  It  may  extend  half-way  to  the  umbilicus. 
It  is  oval  and  symmetrical  in  outline  and  disappears  upon  micturition  or 
catheterization. 


152  MEDICAL  DIAGNOSIS. 

(d)  A  Distended  Stomach. — A  hearty  meal  or  the  large  ingestion  of 
fluid  will  cause  an  area  of  dulness  in  the  epigastrium  which  disappears 
in  the  course  of  digestion.  The  sharp  contrast  between  the  lower  border 
of  the  dulness  and  the  tympanitic  resonance  of  the  transverse  colon 
indicates  the  position  of  the  greater  curvature  of  the  stomach. 

(e)  Fecal  Masses  in  the  Colon. — In  persons  of  sedentary  habits  it 
is  not  uncommon  to  find  areas  of  dulness  corresponding  to  the  course  of 
the  colon,  and  especially  to  the  left  end  of  its  transverse  portion,  which 
disappear  upon  brisk  and  repeated  purgation. 

(f)  Pregnancy.  —  The  oval  area  of  dulness  gradually  developing 
upward  from  the  pelvis,  always  central,  at  first  symmetrical,  later  deflected 
somewhat  laterally,  is  suggestive.  The  diagnosis  of  this  physiological 
condition  under  ambiguous  circumstances  or  in  a  doubtful  case  must  be 
a  guarded  one. 

With  the  above  exceptions  the  percussion  resonance  of  the  abdomen 
is  tympanitic.  Its  pitch  varies  with  the  dimensions  of  the  particular  space 
and  the  tension  of  the  contained  air,  being  relatively  high  as  the  space  is 
small  and  the  tension  great.  The  stomach  and  colon  yield  therefore  a 
percussion  note  of  lower  pitch  than  the  small  intestines.  The  structure 
and  functions  of  these  organs  are,  however,  such  as  to  cause  great  varia- 
tions in  the  size,  tension,  and  relation  of  their  various  parts,  and  lessen  the 
value  of  the  signs  obtained  by  this  method  of  examination.  The  percussion 
signs  are  furthermore  greatly  modified  by  the  thickness  of  the  abdominal 
walls  and  their  general  state  as  to  tension  and  relaxation. 

PERCUSSION  IN  DISEASE  OF  THE  ABDOMINAL  ORGANS. 

Under  ordinary  circumstances  except  as  above  stated  the  abdomen 
in  health  is  everywhere  tympanitic  beyond  the  borders  of  the  liver  and 
spleen.  Persistent  dulness  is  significant  of  morbid  conditions.  It  may  be 
general  or  local,  continuous  with  the  dulness  of  the  liver  or  spleen  or 
separated  from  them,  fixed  or  shifting. 

General  Dulness  of  the  Abdomen. — The  retracted  abdomen  seen 
in  the  wasting  diseases  and  in  oesophageal  and  pyloric  carcinoma,  cholera, 
and  the  pernicious  vomiting  of  pregnancy  is  usually  dull  upon  percussion. 
The  areas  of  tympanitic  resonance  are  limited  in  extent  and  of  irregular 
distribution.  This  is  especially  true  of  the  scaphoid  abdomen  so  often 
observed  in  meningitis,  tumor  of  the  brain,  and  lead  colic.  The  bowels 
are  empty  of  air  and  collapsed. 

The  general  distention  due  to  fat  in  the  walls  and  intra-abdominal 
fat,  fluid  within  the  peritoneal  cavity,  or  abdominal  tumor  yields  dulness 
upon  percussion.  The  bowels  contain  air  but  under  conditions  which 
modify  the  results  of  percussion.  In  the  case  of  an  excess  of  fat  in  the 
walls  the  force  of  the  blow  is  not  transmitted  to  the  underlying  gut;  in 
excessive  omental  fat  the  same  is  true.  Fluid  accumulates  in  the  depend- 
ent parts,  displacing  the  coils  of  intestine,  which  float  upon  the  surface, 
and  yields  dulness  upon  percussion  at  the  lower  levels  with  tympany  above 
shifting  with  change  of  posture,  the  line  between  them  tending  to  maintain 
its  correspondence  with  the  plane  of  the  horizon.    Thus,  in  the  recumbent 


PHYSICAL  DIAGNOSIS:     PERCUSSION. 


153 


posture  there  is  general  dulness  save  in  a  limited  oval  region  around  the 
umbilicus,  over  which  there  is  tympanitic  resonance;  in  the  erect  posture 
the  resonance  of  this  region  is  replaced  by  dulness  while  there  may  be 
demonstrated  a  broad  line  of  tympanitic  resonance  in  the  epigastric  zone, 
previously  dull;  in  the  lateral  postures  the  area  of  resonance  seeks  the  upper 
spaces  and  shifts  alternately  as  the  patient  turns  from  side  to  side.  The 
fluid  commonly  gravitates  slowly  from  region  to  region  and  a  few  moments 
must  be  permitted  to  elapse  before  the  change  of  note  can  be  demonstrated. 
Large  monocysts,  as  of  the  pancreas  or  ovary,  also  yield  fluctuation  and 
general  dulness,  but  the  intestines  do  not  float  at  the  highest  level,  being, 


Fra.  76. — Free   fluid    in   abdominal    cavity — dorsal    decubitus — flatness   in   flanks    and   tympany   ovei 
supernatant  coils  of  intestines. 


FlO.   77. — Free  fluid  in  peritoneal  cavity — lat-  FlO.  78. — Abdominal  tumor — increase  in  antero- 

eral   decubitus     flatness  in  dependent   side   and        posterior  diameter — flatness  centrally  and  tympany 
tympany  above.  in  flank~. 


on  the  contrary,  pushed  aside,  and  causing  resonance  in  the  Hanks,  which 
does  not  change  to  any  great  extent  with  change  of  position  and  does  not 
present  the  oval  area  of  tympanitic  resonance  in  the  umbilical  region  which 
is  characteristic  of  ascites.  The  presence  of  peritoneal  adhesions  and  a  great 
quantity  of  fluid  sometimes  renders  fluctuation  obscure  and  the  results  of 
percussion  uncertain  by  interfering  with  the  free  movement  of  the  superna- 
tant intestines.  Tumors  of  sufficient  size  to  give  rise  to  marked  distention 
and  general  dulness  or  flatness  usually  increase  t  he  anteroposterior  diameter 

ot  the  abdomen  to  a  greater  extent  than  the  bilateral  as  compared  with 
ascites  and  meteorism.     The  enlargement  caused  by  tumor  is  not   usually 

symmetrical.      The  intestines  are  pushed  aside  and  tympanitic  resonance  is 


154 


MEDICAL  DIAGNOSIS. 


elicited  upon  percussion  in  the  flanks  and  especially  upon  the  opposite 
part  of  the  abdomen  to  that  from  which  the  growth  has  developed — on 
the  left  side  in  case  of  tumor  of  the  liver,  on  the  right  in  case  of  tumor  of 
the  spleen,  above  in  tumors  springing  from  the  pelvic  organs,  below  in 
those  springing  from  organs  in  the  epigastric  zone,  and  so  forth,  while  over 
the  tumor  there  is  dulness.  The  list  of  tumors  which  attain  dimensions 
sufficiently  great  to  cause  general  distention  of  the  abdomen  comprises 
cancer,  syphilitic  and  amyloid  disease,  and  hydatid  cysts  of  the  liver; 
malignant  disease  and  multiple  cysts  of  the  kidney;  cancer  of  the  intestines 
and  peritoneum;   ovarian  cysts  and  uterine  fibromata  and  retroperitoneal 

sarcoma.  Very  marked  distention 
may  be  present  in  pancreatic  cyst, 
hydronephrosis  and  tuberculosis  of 
the  mesenteric  glands,  and  Hodgkin's 
disease.  All  these  conditions  yield 
dulness  upon  percussion.  An  impor- 
tant sign  in  the  diagnosis  of  large  neo- 
plasms of  the  retroperitoneal  glands 
arises  from  the  fact  that,  while  the 
intestines  are  in  general  pushed  aside 
by  the  tumor,  the  ascending  or 
descending  colon,  according  to  the 
side  upon  which  the  growth  develops, 
passes  obliquely  across  it  and  yields 
tympanitic  resonance,  at  both  borders 
of  which  dulness  begins. 

Gaseous  distention  of  the  abdo- 
men —  meteorism,  tympany — yields 
tympanitic  resonance  at  all  points 
and  increases  the  vertical  diameter 
of  the  abdomen  by  pushing  the  dia- 
phragm upwards  and  interfering  with 
its  descent.  In  extreme  distention  the  note  becomes  higher  in  pitch, 
shorter  in  duration,  and  diminished  in  intensity  until  it  finally  may  be  dull. 
This  condition  is  commonly  due  to  paresis  of  the  intestinal  wall  and 
occurs  in  peritonitis,  the  advanced  stages  of  the  infectious  fevers,  and 
hysteria.  To  a  less  degree  it  is  present  in  cretinism,  rickets,  and  pseudo- 
hypertrophic paralysis.  Great  dilatation  of  the  stomach  and  congenital 
dilatation  of  the  colon  are  attended  with  general  abdominal  enlargement 
over  which  the  note  is  tympanitic. 

Free  gas  in  the  peritoneal  cavity  may  be  the  outcome  of  a  perforating 
ulcer  of  the  stomach  or  duodenum — peptic  ulcer — or  of  the  ileum  in  enteric 
fever  or  of  the  appendix.  The  accident  which  leads  to  the  escape  of  gas 
is  usually  attended  with  severe  abdominal  pain,  collapse,  and  meteorism. 
Rapid  obliteration  of  liver  dulness  in  an  abdomen  not  previously  much 
distended  is  an  important  sign.  Mere  disappearance  of  the  anterior  liver 
dulness  at  the  margin  of  the  ribs  or  in  the  nipple  line  may  be  a  sign  of  ordi- 
nary meteorism.  If,  however,  liver  dulness  is  present  in  the  infra-axillary 
line  while  the  patient  is  in  the  dorsal  decubitus  and  is  replaced  by  tym- 


Fig.  79. — Tumor  of  left  side  of  abdomen — 
dulness  with  strip  of  tympany  corresponding 
to  colon. 


PHYSICAL  DIAGNOSIS:    AUSCULTATION.  155 

panitic  resonance  when  he  is  turned  upon  the  left  side,  it  may  be  inferred 
that  there  is  free  air  in  the  peritoneal  cavity. 

Local  Areas  of  Dulness. — Spasmodic  local  contractions  of  the  abdom- 
inal muscles  and  phantom  tumors  may  yield  dulness  upon  percussion. 
In  obscure  cases  a  somewhat  deeply  seated  tumor  may  be  examined  by 
percussion,  if  the  walls  are  relaxed,  by  pressing  with  the  pleximeter  hand 
gently  but  firmly  for  a  time  until  the  bowel  is  pushed  aside,  and  the  mass 
may  be  recognized  by  palpation  and  its  percussion  signs  ascertained. 
Any  local  tumor  or  new  growth  gives  rise  to  percussion  dulness  in  that 
area  of  the  abdominal  wall  which  overlies  it.  The  variety  of  such  morbid 
conditions  is  very  great.  The  nature  and  point  of  origin  of  the  most 
important  of  them  have  been  indicated  under  the  heading  Palpation 
in  Diseases  of  the  Abdominal  Organs. 

AUSCULTATION. 

Auscultation  as  a  method  of  physical  diagnosis  is  the  art  by  which 
we  recognize  and  interpret  the  sounds  produced  within  the  body  in  health 
and  disease. 

This  is  the  most  important  of  the  methods  of  physical  diagnosis.  It 
is  essential  to  the  diagnosis  of  diseases  of  the  organs  of  respiration  and 
circulation  and  of  limited  service  in  the  diagnosis  of  diseases  of  the  diges- 
tive organs. 

The  Methods. — Auscultation  is  of  two  kinds, — immediate  or  direct,  in 
which  the  ear  is  applied  directly  to  the  surface  to  be  examined,  and  mediate 
or  indirect,  in  which  a  stethoscope  is  employed.  The  latter  was  practised  by 
Laennec,  the  discoverer  of  auscultation;  the  former  has  since  come  into  use. 

Each  of  these  methods  has  its  peculiar  advantages  in  diagnosis.  Direct 
auscultation  is  useful  for  a  general  survey  of  the  chest,  including  both  its 
respiratory  and  circulatory  phenomena,  the  study  of  broad  areas  and  the 
determination  of  the  presence  or  absence  of  abnormal  signs.  It  also  enables 
us  to  detect  the  signs  of  deep-seated  lesions,  as  central  consolidation  of  the 
lung,  which  are  not  audible  by  the  stethoscope.  Indirect  auscultation,  on 
the  other  hand,  is  preferable  for  the  nice  study  of  the  signs  heard  in  limited 
areas,  the  point  of  maximum  intensity  of  a  murmur  or  the- limits  of  a  fric- 
tion sound.  Just  as  in  palpation  we  use  the  palm  of  the  hand  to  find  and 
estimate  the  extent  of  the  impulse  of  the  heart  and  then  study  its  force  and 
characters  with  the  smaller  and  more  sensitive'  finger-tips,  so  the  experi- 
enced diagnostician  uses  the  two  methods  of  auscultation.  Like  the  other 
methods  of  physical  diagnosis  they  are  not  independent  and  sufficient  of 
themselves,  but  interdependent  and  complementary.  There  is  no  question 
as  to  which  should  he  employed,  since  both  are  necessary:  the  one  for  one 
kind  of  observation,  the  other  for  a  different  kind;  the  one  for  clinical 
research,  the  other  to  control  its  results. 

Many  experienced  auscultators  use  the  direct  method  in  the  exam- 
ination of  the  back  of  the  chest  and  the  stethoscope  for  the  examination 
of  the  anterior  surface,  the  reason  for  this  being  found  in  the  difficulty 
in  reaching  the  supraclavicular  and  axillary  regions  by  the  direct  method, 
the  closer  study  necessary  in  the  examination   of  cardiac  and   pericardial 


156 


MEDICAL  DIAGNOSIS. 


conditions,  and  certain  personal  considerations  which  appeal  to  the  user  of 
the  stethoscope. 

Stethoscopes. — These  instruments  are  made  of  various  materials  and 
shapes.  The  young  auscultator  of  a  mechanical  turn  of  mind  is  very  apt 
to  turn  his  attention  to  the  stethoscope  and  there  are  many  inventions. 
Few  only  deserve  serious  consideration.  The  underlying  principle  is  the 
conduction  of  the  sound.  There  are  two  kinds  of  stethoscopes,  the  single 
and  the  double   or  binaural. 

The  single  stethoscope  was  used  by  Laennec.  The  best  form  is  the 
gun-metal  instrument  with  detachable  hard-rubber  ear-piece  devised  by 
Hawksley  of  London. 

The  double  stethoscope  of  Cammann  of  New  York  consisted  of  a  chest- 
piece  connected  with  two  tubes  fitted  with  ear-pieces.  Many  modifications 
of  this  instrument  have  since  been  made  and  the  double  stethoscope  has 
come  into  general  use.  The  chest-pieces  as  now  made 
consist  of  interchangeable  bell-like  expansions  of  hard  or 
soft  rubber,  or  a  shallow  metal  cup  with  a  hard-rubber 
diaphragm  held  in  place  by  a  metal  ring,  seven-eighths 
of  an  inch  in  diameter  so  as  to  be  applied  to  the  costal 
interspaces,  or  larger;  the  tubes  are  long  and  flexible 
to  enable  the  examiner  to  move  the  chest-pieces  freely 
without  changing  his  position,  while  the  ear-pieces  are 
in  some  instances  attached  to  metal  arms  held  together 
by  a  spring  or  hinged  and  held  in  position  by  a  rubber 
band.  In  other  forms  the  soft-rubber  tubes  are  con- 
nected directly  with  the  chest-piece  and  ear-piece,  the 
latter  retaining  its  place  in  the  meatus  by  its  appropri- 
ate shape  and  size. 

In  selecting  a  stethoscope  attention  should  be  given 
to  the  kind.  It  should  be  an  excellent  conductor  of 
sound  as  tested  by  comparing  several  different  instru- 
ments under  similar  conditions,  and  simple  in  construc- 
tion, durable,  and  convenient  to  carry.  Attention  must  also  be  given  to 
the  particular  instrument  to  see  that  the  ear-pieces  fit  comfortably,  that 
the  pressure  is  right,  and  that  extraneous  sounds  are  excluded. 

With  a  good  instrument,  even  with  the  unaided  ear,  and  a  fair  amount 
of  training  the  sounds  which  constitute  auscultatory  signs  may  be  heard. 
The  problem  in  diagnosis  is  their  proper  interpretation. 

The  phonendoscope  of  Bianchi  consists  of  a  shallow  metallic  circular 
chest-piece  with  vibrating  hard-rubber  disks  and  soft -rubber  tubing  con- 
ductors to  the  ear-pieces.  It  is  readily  applied,  and,  while  it  intensifies  the 
sounds,  does  not  produce  exaggerated  sounds.  It  is  especially  useful  in 
auscultatory  percussion. 

In  the  Bowles  stethoscope  the  chest-piece  is  constructed  with  a 
vibrating  hard-rubber  diaphragm  with  the  attachment  for  the  conducting 
tubes  at  a  right  angle  to  its  central  axis.  Multiple  attachments  are  made 
for  class  demonstration.  The  sounds  are  intensified  and  the  claim  has 
been  made  that  cardiac  murmurs  otherwise  inaudible  may  be  distinctly 
heard.     The  flat   chest-piece  is  especially  serviceable  in  the  examination 


Fig.  80.— Hawksley's 
single  stethoscope. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION. 


157 


of  the  back  of  the  chest  in  persons  too  ill  to  be  moved,  since  it  may,  by  push- 
ing the  bedclothes  down,  be  slipped  under  the  patient's  back  at  different 
points  without  changing  his  position.  Combination  formsin  which  the  Bowles 
attachment  is  fitted  into  the  chest -piece  of  an  ordinary  stethoscope  are  sold. 

The  differential  stethoscope  of  Alison  has  two  chest- 
pieces  with  separate  conducting  tubes.  This  instrument 
enables  the  examiner  to  compare  the  sounds  heard  at 
different  parts  of  the  chest  and  to  study  differences  in 
their  acoustic  properties  as  well  as  in  the  time  of  their 
occurrence.  Notwithstanding  its  value  it  has  not  come 
into  general  use. 

The  Technic  of  Auscultation.  —  The  following  gen- 
eral rules  are  to  be  observed: 

1.  The  patient's  attitude  should  in  so  far  as  possible 
be  comfortable  and  unconstrained. 

2.  Let  the  chest  be  bared  or  covered  only  with  a 
towel  or  single  layer  of  undergarment.  When  the  steth- 
oscope is  used  it  is  better  to  have  the  chest  bare. 
When  direct  auscultation  is  practiced  it  is  convenient 
and  fitting,  though  not  essential,  to  have  a  layer  of  thin 
stuff  between  the  ear  of  the  examiner  and  the  skin  of 
the  patient.  Auscultation  cannot  be  properly  performed 
through  the  patient's  ordinary  clothing.  The  superim- 
posed layers  of  several  garments,  silk  fabrics,  and  the 
suspenders  or  corsets  not  only  mask  the  sounds  within 
the  chest  but  also  give  forth  sounds  of  their  own  upon 
respiratory  movements. 

3.  In  indirect  auscultation  apply  the  chest-piece 
of  the  stethoscope  closely  to  the  surface,  steadying  it 
by  grasping  it  between  the  thumb  and  index  finger. 

4.  If  the  single  stethoscope  is  used,  it  must  be 
applied  perpendicularly  to  the  surface.  If  it  is  tilted, 
external  sounds  are  not  excluded. 

5.  The  stethoscope  must  be  applied  very  lightly  in 
auscultation  of  Mood-vessels.  The  rim  of  the  instru- 
ment may  cause  a  murmur  in  the  vessels  at  the  root  of 
the  neck  or  in  the  abdominal  aorta  by  causing  the 
physical  condition  to  which  such  murmurs  are  due. 
namely,  sudden  narrowing  of  the  lumen — stenosis. 

G.  Examine  the  chest  in  a  routine  manner  first  at 
one  apex,  then  al  the  other,  and  al  corresponding  points 
upon  the  two  sides  from  above  downwards,  in  front, 
behind,  and  at  the  -ides.  Comparison  and  contrast  are  essential  to  auscul- 
tation. Equally  importanl  are  the  differences  in  the  sounds  upon  ordinary 
quiet  breathing,  full  respiration,  and  coughing.  The  respigitoiv  signs  arc 
to   lie   considered   also   in   connection    with   the  signs   upon   auscultation   of 

the  voice.     In  very  serious  cases,  where  the  patient   cannot   l»e  disturbed 
or  where  the  condition  can  be  at  once  recognized,  a  complete  systematic 

examination    may   be  omitted. 


Fig.  81.     Bowles  bin- 
aural stel  hosoope. 


158  MEDICAL  DIAGNOSIS. 

7.  Examine  the  heart  in  the  same  systematic  manner,  placing  the 
stethoscope  over  the  puncta  maxima  in  turn  and  noting  the  direction  in 
which  sounds  or  murmurs  are  propagated  together  with  the  presence  or 
absence  of  friction  sounds,  etc. 

8.  Consider  the  patient.  Do  not  fatigue  him  unnecessarily  either  in 
mind  or  body.  Do  not  cause  distress  by  undue  pressure  of  the  stethoscope 
or  by  insisting  upon  the  repetition  of  deep  breathing  or  cough  when  they 
give  rise  to  pain.  Conduct  the  examination  with  method,  dispatch,  and 
regard  for  his  feelings  and  do  not  repeat  it  with  unnecessary  frequency. 

9.  Consider  yourself.  Assume  a  position  which  enables  you  to  place 
your  ear  or  the  stethoscope  in  accurate  relation  to  the  surface  to  be  ex- 
amined. Use  such  patience  with  skill  as  will  render  the  examination 
satisfactory  to  you.  If,  despite  your  efforts,  the  results  do  not  justify 
a  diagnosis,  defer  expressing  an  opinion  until  you  have  an  opportunity 
of  repeating  the  examination  under  more  favorable  circumstances.  In 
dispensary  and  hospital  practice  be  on  your  guard  against  vermin. 

In  children  auscultation  is  even  more  valuable  in  the  diagnosis  of 
diseases  of  the  chest  than  in  adults.  Owing  to  the  great  elasticity  of  the 
walls  of  the  chest  and  the  corresponding  increase  of  resonance,  percussion 
is  of  much  less  general  applicability.  Dulness,  even  when  the  physical 
conditions  which  cause  it  are  present,  is  not  usually  so  marked  nor  its 
limits  so  easily  recognized,  nor  do  we  derive  the  same  advantage  from 
comparing  and  contrasting  the  two  sides,  since  the  acute  pulmonary 
affections  of  early  life  are  much  more  frequently  double  than  those  after 
the  second  dentition. 

In  children  the  back  of  the  lungs  should  be  first  listened  to.  The 
diagnosis  may  often  be  made  at  once  upon  a  careful  and  systematic  exami- 
nation of  the  back  alone,  after  taking  the  history  of  the  illness  and  noting 
the  symptoms.  This  is  especially  true  in  acute  and  chronic  bronchitis, 
croupous  and  bronchopneumonia,  and  pleural  effusion.  Crying  is  of  great 
assistance.  The  deep  inspirations  develop  the  signs  characteristic  of  the 
lesions  which  are  present,  and  we  also  obtain  the  signs  which  arise  from  the 
character  and  modifications  of  the  vocal  resonance. 

The  position  in  which  the  child  is  examined  by  auscultation  should 
vary  with  its  age.  Very  young  infants  may  be  examined  in  either  a  lying 
or  sitting  posture  on  the  lap  of  the  nurse  or  upon  a  pillow;  or  they  may 
be  held  in  the  arms  of  an  attendant  who  presents  one  part  of  the  chest 
after  another  to  the  ear  of  the  physician.  The  physician  himself  may 
hold  the  baby  seated  upon  his  left  hand  and  supported  by  his  right  hand 
applied  to  the  front  of  its  chest  and  listen  to  its  back  with  his  right  ear. 
Older  children  may  be  held  seated  upon  the  forearm  of  the  mother  or 
nurse  with  the  head  resting  upon  her  shoulder  while  the  physician  listens 
to  the  back. 

The  difficulty  with  beginners  in  auscultation  is  that  they  hear  too 
much.  They  cannot  at  first  discriminate  between  sounds  that  are  signifi- 
cant and  those  which  are  irrelevant.  The  power  to  do  this  comes,  however, 
with  practice. 

The  most  important  of  the  sounds  which,  by  a  process  of  selective 
attention,  the  young  auscultator  must  learn  to  disregard  are  the  following: 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  159 

1.  Outside  Noises. — A  quiet  room  and  silence  are  desirable  but  cannot 
always  be  secured.  We  must  train  ourselves  not  to  hear  extraneous  sounds 
while  engaged  in  listening  to  those  which  are  the  object  of  our  immediate 
attention.  Properly  fitting  ear-pieces  and  accurate  adjustment  of  the  chest- 
piece  of  the  stethoscope  are  of  help  in  excluding  the  sounds  which  we  do 
not  want  to  hear. 

2.  Accidental  noises  produced  by  the  stethoscope.  These  comprise 
friction  rubs  of  the  instrument  upon  the  skin,  especially  when  it  is  dry  and 
harsh  or  covered  with  coarse  hair;  friction  rubs  of  the  auscultatory  fingers, 
or  his  sleeves,  or  the  like,  upon  the  stethoscope;  friction  or  fine  snapping 
sounds  caused  by  the  movement  of  one  part  upon  another  of  an  adjustable 
stethoscope  of  several  pieces;  sounds  made  by  the  breath  of  the  examiner 
upon  the  rubber  cross-piece  or  steel  spring  of  the  stethoscope,  and  finally 
the  humming  or  buzzing  sound — tinnitus — made  by  the  ear-pieces.  Most  of 
these  sounds  are  easily  recognized  and  avoided.  The  last  is  to  be  dimin- 
ished by  very  careful  adjustment  of  the  ear-pieces  and  overcome  by  usage. 

3.  Adventitious  sounds  conducted  by  the  stethoscope  but  not  properly 
constituting  auscultatory  signs.  The  sounds  made  by  the  friction  of  the 
clothing  and  coarse  hairs  are  very  confusing.  The  first  are  easily  obviated; 
the  second  by  practice,  by  applying  the  chest-piece  beyond  the  borders 
of  the  hairy  patch,  or  by  the  use  of  oil.  Sounds  produced  by  the  contraction 
of  muscular  masses  may  often  be  heard,  especially  upon  deep  breathing, 
in  various  parts  of  the  chest  and  in  particular  over  the  pectorals  and  tra- 
pezii.  These  sounds  are  faint  and  variable  in  kind  but  often  quite  distinct. 
They  can  be  produced  upon  the  forcible  contraction  of  any  muscle.  The 
thenar  mass,  for  example,  when  contracted  with  the  stethoscope  applied 
over  it,  affords  a  good  illustration  of  such  sounds.  Cabot  has  suggested 
that  auscultatory  sounds  described  as  "crumpling,"  "obscure,"  "distant." 
and  "indeterminate"  rales  are  in  reality  due  to  muscular  contractions. 
The  fact  that  such  sounds  are  very  often  associated  with  distinct  or  easily 
recognized  rales  and  other  evidences  of  pulmonary  disease  and  occur  in 
individuals  with  atrophic  chest  muscles,  should  put  us  on  our  guard  against 
hasty  conclusions. 

Auscultation  as  Applied  to  the  Diagnosis  of  Diseases 
of  the  Organs  of  Respiration. 

It  is  of  practical  importance  that  the  movement  of  the  tidal  air  on 
quiet  breathing  is  in  many  persons  not  sufficient  to  cause  auscultatory 
phenomena  of  significance  It  becomes  necessary  then  to  listen  to  the 
chesl  during  deep  or  forced  respiration.  If  the  patient  is  stupid  or  awk- 
ward, difficulties  arise.  He  holds  his  breath,  or  pants,  or  makes  strange 
noises,  Or  does  not  appear  able  to  take  a  deep  breath.  Yon  show  him  how- 
to  bicat  he  for  the  examination  or  you  ask  him  to  COUgh,  listening  to  the 
respiratory  signs  during  the  deep  inspiration  which  follows  or  precedes, 
Or  you  ask  him  to  count  as  long  as  he  can  with  a  single  breath.  The  full 
breath  which  follows  enables  US  to  ascertain  the  presence  or  absence  of 
abnormal  signs.  These  difficulties  are  usually  encountered  in  subacute 
and  doubtful  cases.  Jn  acute  cases  and  in  chronic  cases  with  advanced 
lesions  the  signs  are  commonly  distinctive  upon  ordinary  breathing. 


160  MEDICAL  DIAGNOSIS. 


THE  SIGNS  IN  HEALTH. 


Auscultation  of  the  normal  chest  discovers  two  respiratory  sounds 
which  are  typical: 

1.  Tracheal,  bronchial,  or  tubular  breathing, 

2.  Vesicular  breathing,  and  combinations  of  these  types  in  varying 
degree,  namely, 

3.  Bronchovesicular  breathing. 

1.  Tracheal,  bronchial,  or  tubular  breathing  is  heard  when  the 
stethoscope  is  placed  over  the  thyroid  cartilage,  over  the  trachea  in  the 
episternal  notch,  and  in  the  upper  part  of  the  interscapular  space  upon  the 
right  side — normal  bronchial  respiration.  Sometimes  nearly  pure  bronchial 
breathing  can  be  heard  in  health  over  the  manubrium  sterni  or  the  three 
lower  cervical  vertebra?. 

It  has  its  origin  in  the  larynx,  and  is  sometimes  for  that  reason  spoken 
of  as  laryngeal,  and,  from  the  situations  at  which  it  is  heard  in  health, 
tracheal  or  bronchial.  Since  it  is  conducted  along  the  column  of  air  in  the 
bronchial  system  and  probably  also  along  its  elastic  walls  and  resembles 
the  sound  produced  by  breathing  through  a  tube,  it  is  called  tubular. 

This  type  of  breath  sound  is  heard  with  inspiration  and  expiration, 
these  two  elements  of  the  sound  being  separated  by  a  brief  interval  of  silence 
at  the  end  of  inspiration.  Its  quality  is  bronchial,  tubular,  or  blowing; 
its  pitch  relatively  high  as  compared  with  vesicular  breathing.  The  expira- 
tory element  is  slightly  more  intense,  usually  of  higher  pitch,  and  slightly 
more  prolonged  than  the  inspiratory  part.  It  may  be  imitated  by  slowly 
breathing  through  the  hollow  of  the  hand,  closed  by  flexing  the  fingers 
till  their  tips  touch  thenar  and  hypothenar  eminences,  or  through  the 
lips  and  teeth  held  in  the  position  to  sound  the  German  ch. 

It  is  produced  at  the  chink  of  the  glottis  where  the  air  upon  inspira- 
tion and  expiration  is  thrown  into  eddies  or  swirls — fluid  veins.  For  the 
reason  that  a  similar  mechanism  is  involved  in  the  production  of  vesicular 
breathing  and  cardiac  and  vascular  murmurs,  it  may  properly  be  considered 
at  this  point. 

The  Theory  of  Fluid  Veins.  —  Chauveau  pointed  out  the  fact  that 
when  a  fluid  is  forced  under  pressure  from  a  narrow  into  a  wider  tube  or 
channel,  or  through  a  narrow  opening  into  a  large  cavity  or  space,  it  is 
thrown  into  swirls  or  eddies,  the  vibrations  of  which,  transmitted  to  the 
enclosing  substance  and  to  the  surrounding  air,  are  recognized  as  auditory 
phenomena.  These  swirls  have  been  called  fluid  veins.  They  are  currents 
within  currents,  and  their  vibrations  are  not  only  transmitted  laterally 
but  also  longitudinally  in  the  stream  in  which  they  exist,  so  that  the  sounds 
are  heard  over  the  point  at  which  they  are  produced  and  at  a  distance  in 
the  direction  of  the  flow.  The  extent  and  force  of  these  swirls  and  the 
consequent  loudness  of  the  sound  by  which  they  are  represented  depend 
to  some  extent  upon  the  composition  and  density  of  the  fluid  but  mainly 
upon  the  force  of  the  current.  The  student  will  realize  the  nature  of  fluid 
veins  and  the  part  they  play  in  the  production  of  the  bronchial  respiration 
and  the  vesicular  murmur, — for  the  air  acts  in  the  same  way  as  other 
fluids, — and  especially  their  part  in  the  production  of  endocardial  and  vas- 


PHYSICAL  DIAGNOSIS:    AUSCULTATION.  161 

cular  murmurs,  if  he  considers  the  course  of  a  rivulet  which  flows  at  one 
time  down  a  steep  and  rapid  course,  and  at  another  along  a  nearly  level 
bed  with  even  sides  and  a  smooth  bottom,  and  now  as  a  gentle  stream  and 
again  with  considerable  force.  The  quiet  current  flowing  in  even  banks 
is  smooth  and  noiseless,  while  the  little  torrent  in  its  rocky  bed  has  its 
surface  thrown  into  countless  screw-like  swirls,  and  murmurs  or  roars, 
according  to  the  force  and  volume  of  the  water.  The  stream  is  an  open 
channel;  the  respiratory  and  vascular  spaces  are  closed  tubes;  but  the 
mechanism  by  which  the  sounds  are  produced  is  the  same  in  each.  It  is 
evident  that  the  intensity  of  the  bronchial  respiration  will  vary  with  the 
quantity  of  the  tidal  air,  the  force  with  which  it  passes  through  the 
glottis,  the  distance  at  which  it  is  heard,  and  the  conducting  properties 
of  the  media  through  which  it  is  transmitted.  Variations  in  pitch  depend 
upon  the  size  and  shape  of  the  spaces — pharynx,  buccal  cavity,  trachea, 
etc. — which  constitute  resonating  chambers  in  relation  with  the  larynx. 
We  are  thus  prepared  to  find  wide  differences  in  intensity  and  pitch  in  the 
breath  sounds  which  have  the  characteristic  tubular  or  bronchial  quality. 

2.  Vesicular  Breathing. — Respiration  of  this  type  is  heard  when  the 
stethoscope  is  placed  elsewhere  over  the  chest  where  the  lungs  are  in 
contact  with  the  chest  wall,  namely,  in  the  front  of  the  thorax  with  the 
exception  of  the  area  of  superficial  cardiac  and  hepatic  dulness,  in  the 
infrascapular  regions  and  in  the  axillary  and  the  upper  part  of  the  infra- 
axillary  regions.  In  the  right  interscapular  region  the  breathing  in  health 
is  usually  bronchovesicular,  the  vesicular  element  predominating. 

This  sound  has  its  origin  in  the  parenchyma  of  the  lung,  and  is  due  to 
the  transmission  of  the  vibrations,  caused  by  fluid  veins  or  swirls  in  the 
air  passing  into  and  out  of  the  infundibula  and  alveoli,  to  the  surface  of 
the  chest.  The  hypothesis  that  the  vesicular  respiration  is  merely  a  modi- 
fication of  the  bronchial  appears  to  me  to  rest  upon  insufficient  facts.  This 
type  of  breathing  is  heard  throughout  the  whole  act  of  inspiration,  and  is 
immediately  followed,  without  an  interval  of  silence,  by  a  short  but  incon- 
stant expiratory  sound.  The  inspiratory  portion  is  low  in  pitch  as  com- 
pared with  bronchial  respiration,  of  variable  intensity,  and  has  the  char- 
acteristic quality  described  as  vesicular,  which  is  to  be  learned  only  by 
experience.  It  is  sometimes  called  the  vesicular  murmur,  and  it  may  be 
of  service  to  the  student  to  note  that  it  possesses  the  distinguishing  peculiar- 
ity of  murmurs,  namely,  that  they  are  sounds  made  up  of  a  multitude  of 
small  sounds,  all  having  about  the  same  acoustic  properties,  as  we  speak 
of  the  murmur  of  a  crowd,  of  the  leaves  of  the  forest,  of  the  sea,  and  so  on. 
The  expiratory  part  is  still  lower  in  pitch  than  the  inspiratory,  much  less 
intense,  frequently  absent  altogether,  and  does  not  exceed  one-third  the 
length  of  t  he  latter. 

The  vesicular  murmur  is  not  equally  intense  in  nil  parts  of  the  chest. 
It  is  loudest  in  the  infraclavicular,  axillary,  and  infrascapular  regions,  and 
fainter  at  the  liases  in  front  and  behind.  Thai  is  to  say,  it  is  loudest  over 
large  masses  of  lung  tissue  and  faintest  over  the  thin  wedge-shaped  borders. 

But  it  is  also  less  distinctly  heard  in  the  mammary  and  scapular  regions. 
We  conclude  therefore  that   it    is  not    well  conducted  through  thick  layers 
of  muscle,  hone,  and  tat.      Wherever  heard,  whether  loud  or  taint.it  retains 
11 


162  MEDICAL  DIAGNOSIS. 

its  characteristic  breezy  quality  and  low  pitch,  and  the  relative  duration, 
intensity,  and  pitch  of  the  inspiratory  and  expiratory  elements  are  preserved. 

The  vesicular  murmur  is  feeble  and  distant  on  shallow  breathing  and 
intense  upon  deep  breathing,  especially  after  prolonged  deep  breathing  as 
after  exertion.  It  is  intense  over  the  unaffected  Fung  in  cases  in  which  the 
opposite  lung  has  been  thrown  out  of  service  by  disease,  and  in  healthy  chil- 
dren, hence  it  is  spoken  of,  when  thus  intensified,  as  "puerile"  or  "exagger- 
ated" respiration.  Intense  vesicular  respiration  somewhat  modified  is  spoken 
of  as  "rough";  just  as  bronchovesicular  respiration  is  often  called  "harsh." 

3.  Bronchovesicular  Breathing.  —  This  form  of  respiration,  as  the 
name  indicates,  has  the  characteristics  of  both  bronchial  and  vesicular 
breathing  and  consists  in  fact  of  a  breath  sound  in  which  both  are  present. 
It  is  heard  in  the  normal  chest  very  often,  but  not  invariably  directly  below 
the  right  clavicle,  and  quite  constantly  at  the  sternal  borders  opposite  the 
lower  part  of  the  manubrium  and  in  the  upper  portions  of  the  interscapular 
spaces,  namely,  in  situations  in  which  both  sounds  are  within  range  of 
hearing.  Many  of  the  difficulties  regarding  bronchovesicular  respiration 
are  solved  when  we  recognize  the  fact  that  it  is  made  up  of  the  two  forms 
in  varying  degrees  of  combination,  so  that  it  sometimes  presents  the  traits 
of  bronchial  breathing  slightly  modified  by  the  admixture  of  faint  vesicular 
breathing  and  sometimes  those  of  vesicular  breathing  slightly  modified 
by  bronchial,  and  between  these  two  we  encounter  every  grade  of  admixture. 
This  gradation  by  which  the  breath  sound  passes  from  bronchial  to  the 
vesicular  respiration  may  be  heard  in  the  normal  chest  by  moving  the 
stethoscope  from  point  to  point,  starting  at  that  part  of  the  manubrium 
over  which  bronchial  breathing  is  heard  and  advancing  towards  the  nipple 
where  the  vesicular  murmur  alone  can  be  recognized.  The  inspiration 
becomes,  as  we  proceed,  lower  in  pitch,  less  intense,  and  longer  in  duration, 
and  the  expiration  also  lower  in  pitch  and  less  intense,  but  shorter  in 
duration.  The  interval  'of  silence  which  is  characteristic  of  bronchial 
respiration  is  filled  by  the  vesicular  element  in  bronchovesicular  respiration. 
This  interval  of  silence  is  present  in  bronchial  breathing  because  the  swirls 
— fluid  veins — by  which  the  vibrations  causing  the  sound  are  produced, 
arise  at  a  single  point,  the  glottis,  and  there  is  at  that  point  an  interval  of 
equilibrium  between  the  flood  tide  of  inspiratory  and  the  ebb  tide  of  expira- 
tory air.  The  vesicular  murmur,  on  the  other  hand,  is  produced  at  a 
multitude  of  different  points,  and  the  moment  of  silence  is  as  variable  as  the 
individual  little  sounds  which  cover  the  whole  time  of  the  inspiratory 
act,  since  vesicles  at  the  distant  periphery  of  the  lung  are  still  expanding 
when  those  nearer  the  inlet  have  ceased  to  dilate. 

The  conditions  which  modify  the  bronchial  respiration  as  a  physical 
sign  and  those  which  modify  the  vesicular  murmur  also  modify  the  broncho- 
vesicular breathing.  It  therefore  presents  differences  in  intensity,  dura- 
tion, and  pitch,  corresponding  to  variations  in  the  quantity  and  force  of 
movement  of  the  tidal  air,  to  the  size  and  shape  of  the  resonating  chambers 
formed  by  the  upper  air  spaces  and  the  tracheobronchial  system  and  the 
physical  condition  of  the  intervening  tissues  through  which  the  sounds  are 
conducted  to  the  ear.  The  qualities  of  the  two  component  types  of  breath- 
ing, though  they  vary  in  proportion,  are  not  changed. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  163 

It  is  essential  for  the  student  to  become  familiar  with  these  three 
forms  of  normal  breath  sounds  and  the  localities  in  which  they  may  be 
heard  in  the  normal  chest.  Familiarity  with  normal  physical  signs  is  the 
first  step  towards  the  recognition  of  those  which  are  abnormal. 

Bronchial  breathing  is  heard  in  the  front  of  the  neck  and  over  the 
upper  part  of  the  manubrium,  vesicular  breathing  over  the  greater 
part  of  the  chest,  as  above,  because  the  mechanism  by  which  they  are 
respectively  produced  is  situated  in  the  regions  indicated.  Broncho- 
vesicular  respiration  is  heard  normally  over  the  lower  part  of  the  manu- 
brium and  laterally  to  it  and  in  the  interscapular  spaces  because  both  its 
factors  are  within  the  range  of  hearing.  Bronchial  respiration  is  heard  in 
the  right  interscapular  space  and  bronchovesicular  respiration  is  more 
prominent  (bronchial)  over  the  upper  part  of  the  right  lung  by  reason  of 
the  larger  size  and  higher  origin  of  the  large  bronchus  on  the  sight  side. 

Bronchial  or  tubular  breathing  is  conducted  in  the  column  of  air  in 
the  bronchial  tree  to  its  remote  twigs.  It  is  not  conducted  to  the  surface 
of  the  chest  because  the  vibrations  are  on  the  one  hand  lost  in  the  mass 
of  cushiony,  elastic  vesicular  tissue  which  constitutes  the  lung  parenchyma, 
and  on  the  other  hand  the  bronchial  sound  is  drowned  in  the  vesicular 
murmur.  When  this  tissue  becomes  solidified  by  compression — atelectasis 
— or  by  an  exudate — pneumonia,  tuberculosis — the  vesicular  murmur  is 
done  away  with  and  the  vibrations  conducted  by  the  bronchial  tubes  are 
freely  transmitted  to  the  surface. 

THE  SIGNS  IN  DISEASE. 

The  auscultatory  phenomena  which  constitute  abnormal  or  morbid 
physical  signs  are  (a)  variations  in  the  intensity  and  rhythm  of  the  breath 
sounds,  (b)  normal  physical  signs  heard  in  abnormal  situations,  and  (c) 
purely  adventitious  sounds. 

(a)  Variations  in  Intensity  and  Rhythm. — Bronchial  Respiration- 
It  has  been  explained  that  bronchial  respiration  heard  beyond  the  limits 
of  certain  regions  of  the  chest  in  which  it  is  normally  present  is  usually 
due  to  the  consolidation  of  lung  tissue — atelectasis;  presence  of  an  exudate, 
as  in  pneumonia,  tuberculosis,  etc.  It  may,  however,  arise  in  connection 
with  cavities  in  the  lungs  or  pneumothorax.  Under  these  circumstances 
there  are  layers  and  masses  of  compressed  or  consolidated  lung  tissue 
present  and  the  peculiar  modification  of  the  bronchial  respiration  is  prob- 
ably due  to  the  fact  that  the  cavity  acts  as  a  resonating  space.  Bronchial 
respiration  varies  greatly  in  pitch.  This  variation  is  the  outcome  of  com- 
plex conditions  not  fully  understood,  but  has  been  attributed  to  the  rela- 
tive size  of  the  tubes  or  cavities  from  which  the  sound  is  directly  conducted 
through  consolidated  tissue  to  the  ear.  The  pitch  is  usually  high  and  the 
sounds  whiffing  or  snoring  in  pneumonia  of  the  lower  lobes,  especially  in 
children,  and  low  and  the  sound  soft   and  sighing  or  metallic  over  cavities. 

The  following  varieties  of  bronchial  respiration  are  tn  be  especially 
considered : 

1.  Feeble  mul  distant  bronchial  respiration  is  ofteD  heard  in  central 
pneumonia    and    pulmonary    infarct    ami    over   a    pleural    effusion.      In   the 


164  MEDICAL  DIAGNOSIS. 

former  case  the  bronchial  breathing  may  be  only  heard  upon  deep  inspira- 
tion and  is  therefore  inconstant;  in  the  latter  it  is  frequently  so  faint  as 
to  be  overlooked.  The  sound  is  conducted  by  the  chest  wall  or  by  tense 
adhesions,  the  result  of  former  attacks  of  pleurisy. 

2.  Intense  bronchial  breathing  usually  conveys  the  sensation  of  being 
close  to  the  ear,  that  is,  well  conducted.  It  accompanies  dense  consolida- 
tion of  the  lung  in  which  vicarious  or  supplemental  respiration  is  well 
established. 

3.  Absence  of  bronchial  respiration  or  its  sudden  disappearance  under 
conditions  in  which  the  mechanism  for  its  conduction  exists  may  be  due 
to  the  plugging  of  a  large  bronchus  with  a  mass  of  tenacious  exudate. 
The  disappearance  of  cavernous  or  amphoric  respiration  often  results  from 
the  accumulation  of  fluid  within  the  walls  of  the  cavity.  Under  these  cir- 
cumstances the  bronchial  respiration  returns  after  cough  and  expectoration. 

4.  Cavernous  respiration  is  a  variety  of  bronchial  breathing  sometimes 
heard  over  a  cavity.  It  is  low  in  pitch,  soft  in  quality,  and  the  expiratory 
element  is  prolonged. 

5.  Amphoric  respiration  is  a  variety  which  has  the  peculiar  quality 
heard  when  one  produces  a  sound  by  blowing  across  the  mouth  of  an  empty 
jar  or  bottle.  The  pitch  is  variable,  usually  low,  and  the  sound  is  hollow, 
metallic,  and  musical.  Amphoric  respiration  is  never  heard  over  the  normal 
chest,  and  indicates  a  superficial  cavity  with  rigid  walls — or  pneumothorax 
— having  free  communication  with  a  large  bronchus.  The  sound  may  be 
imitated  by  whispering  "who"  with  some  force  and  the  lips  held  rigid. 

Vesicular  Respiration  -  The  normal  vesicular  murmur  undergoes 
modifications  in  intensity  and  rhythm  which  are  of  diagnostic  significance. 

1.  Feeble  vesicular  respiration  primarily  indicates  diminution  in  the 
quantity  and  energy  of  the  movement  of  the  tidal  air.  Hence  it  is  present 
in  varying  degrees  in  quiet  breathing  in  aged  and  bed-ridden  persons, 
in  paretic  conditions  of  the  respiratory  muscles,  including  the  diaphragm, 
when  the  movement  of  the  diaphragm  is  impeded  by  meteorism,  ascites, 
abdominal  tumor,  or  pregnancy.  The  vesicular  murmur  is  often  feebly 
heard  because  it  is  poorly  conducted,  as  in  very  thick  chest  walls.  In 
pleural  adhesions  the  expansion  of  the  periphery  of  the  lung  may  be  em- 
barrassed, and  with  thickening  conduction  is  also  impaired.  A  thin  layer 
of  effusion  or  a  tumor  acts  in  the  same  way.  In  pneumothorax  the  lung 
is  compressed  and  removed  from  contact  with  the  chest  wall,  and  the 
vesicular  murmur,  if  heard  at  all,  is  faint  and  distant.  In  acute  bronchitis 
the  swelling  of  the  mucosa  and  the  presence  of  the  exudate  interfere  with 
the  access  of  air  to  the  vesicles  and  proportionately  enfeeble  the  vesicular 
murmur,  especially  over  the  lower  lobes.  In  chronic  bronchitis  enfeeble- 
ment  is  brought  about  by  the  accompanying  emphysema  and  restricted 
movements  of  the  chest. 

In  congestion  and  oedema  of  the  lungs  the  murmur  is  enfeebled. 

Emphysema  by  impairing  the  elasticity  of  the  lungs  and  restricting 
the  respiratory  excursus  increases  the  residual  and  diminishes  the  tidal  air, 
thus  rendering  the  vesicular  murmur  faint  and  in  rare  cases  almost 
wholly  abolishing  it.  Pain,  as  in  pleurisy,  restricts  the  respiratory 
movement  and  renders  the  vesicular  sound  faint. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  165 

Occlusion  of  the  upper  air-passages,  as  by  spasm,  oedema  of  the  glottis, 
the  presence  of  an  exudate,  as  in  diphtheria,  quinsy,  or  retropharyngeal 
abscess,  renders  the  murmur  feeble  in  proportion  to  the  extent  of  the 
obstruction.  Pressure  upon  the  trachea  or  a  primary  bronchus  by  aneurism, 
tumor,  or  enlarged  lymph-gland  acts  in  the  same  way.  A  foreign  body 
or  a  plug  of  tenacious  mucus  in  a  bronchus  enfeebles  the  respiratory  murmur 
in  the  corresponding  region  to  a  degree  proportionate  to  the  stenosis.  In 
such  conditions  the  occurrence  of  rales  obscures  the  enfeeblement  of  the 
respiratory  sounds  and  the  latter  will  be  overlooked  unless  made  the 
subject  of  especial  attention. 

2.  Absence  of  the  vesicular  murmur  may  be  noted  over  an  area  of  the 
chest  more  or  less  extensive  when  the  obstruction  to  a  bronchus  in  any  of 
the  foregoing  conditions  is  complete.  Marked  obstruction  of  the  upper  air- 
passages  is  at  once  followed  by  the  signs  of  asphyxia.  The  murmur  is 
absent  over  the  greater  part  of  the  chest  in  rare  cases  of  advanced  emphy- 
sema, and  no  respiratory  sound  is  heard  over  a  pneumothorax  not  com- 
municating with  a  bronchus,  a  large  pleural  effusion  and  locally  over  limited 
areas  in  some  cases  of  cirrhosis  of  the  lung  and  at  the  apex  in  rare  instances 
in  beginning  tuberculosis. 

3.  Intensified  or  exaggerated  vesicular  breathing — puerile,  vicarious,  or 
compensatory  respiration — is  normal  in  childhood  and  gradually  decreases 
until  some  time  before  puberty  the  intensity  of  the  sound  becomes  that 
of  adult  life.  It  occurs  in  health  after  exertion  and  in  dyspncea  from 
almost  any  cause  in  which  there  is  no  obstruction  to  the  entrance  of  air. 
It  occurs  over  one  lung  when  the  other  is  put  out  of  service,  as  in  pneu- 
monia, large  effusion,  tumor,  etc.,  and  in  some  instances  over  a  portion 
of  one  lung  under  similar  conditions,  hence  the  adjectives  vicarious  and 
compensatory. 

4.  Derangements  of  rhythm  occur  in  emphysema,  in  which  the  loss  of 
elasticity  relatively  prolongs  the  expiratory  act  and  the  expiratory  sound; 
in  asthma,  in  which  the  dyspnoea  is  expiratory,  in  the  ordinary  dyspncea 
or  panting  of  great  exertion,  in  which  the  inspiratory  and  the  expiratory 
breal  h  sounds  are  nearly  equal,  and  in  various  forms  of  inspiratory  dyspnoea 
which  arc  attended  by  diminution  of  the  intensity  and  prolongation  of 
the  inspiratory  element  of  the  vesicular  murmur. 

5.  Interrupted  or  cogwheel  inspiration  is  characterized  by  a  series  of  t  wo, 
t  ln'fc.  or  four  inspiratory  sounds  instead  of  the  normal  continuous  murmur. 
It  indicates  in  some  instances  a  fault  in  the  muscular  function  and  occurs 
during  periods  of  excitement  or  during  a  chill;   more  commonly  il  is  a  sign 

of  early  pulmonary  tuberculosis,   the  air  entering  adjacent    lobules  in  turn 

as  the  force  of  inspiration  increases.  It  is  usually  heard  in  limited  areas. 
When  restricted  t<>  the  precordial  space  it  i<  significant  of  pressure  of  the 

heart  upon  the  borders  of  the  lung— cardiopulmonary  murmur.     In  s e 

instances  the  respiratory  sound  is  not  actually  broken,  but  wavy  or  jerky, 
and  is  then  described  under  these  terms.  It  is  uot  rarely  present  in  tuber- 
culosis before  the  disease  has  shown  itself  by  other  signs,  and  individuals 

who    present    it    should    be  carefully    watched.      In   other   cases  it    is   wholly 

without  diagnostic  significance,  which  it  acquires  only  in  conjunction  with 
other  physical  signs  or  I  he  symptoms  of  pulmonary  disease. 


166  MEDICAL  DIAGNOSIS. 

(b)  Normal  Physical  Signs  in  Abnormal  Situations. — Normal  Sounds 
Heard  in  Abnormal  Situations. — Note  the  relative  duration  of  the  inspir- 
atory and  expiratory  sounds  and  determine  the  presence  or  absence  of  an 
interval  of  silence  between  them  and  the  quality  of  the  sound,  whether  soft 
and  breezy — vesicular  murmur;  blowing  and  tubular — bronchial  breathing; 
or  whether  these  qualities  are  both  present — bronchovesicular.  The  most 
important  facts  for  the  beginner  in  the  recognition  of  bronchovesicular  respi- 
ration are  the  prolongation  and  relatively  high  pitch  of  the  expiratory  sound. 

Perfectly  normal  vesicular  respiration  is  rarely  heard  in  other  than  its 
extensive  normal  domain  in  the  chest.  The  rare  cases  of  dextrocardia  are 
attended  with  dislocation  of  the  precordial  space,  and  fibroid  contraction 
of  one  lung  frequently  displaces  the  border  of  the  opposite  lung  towards 
the  affected  side  so  that  it  occupies  the  area  of  superficial  cardiac  dulness 
in  whole  or  in  part.  The  modified  respiration  of  emphysema,  faint  and 
prolonged,  is  sometimes  heard  in  the  precordia  and  over  the  upper  normal 
area  of  the  liver  dulness. 

Bronchovesicular  and  bronchial  respiration  are  on  the  contrary  com- 
mon and  significant  signs  of  disease  in  the  chest.  The  lesions  are  commonly 
progressive,  and  bronchovesicular  usually,  both  in  acute  and  chronic  affec- 
tions, precedes  and  progressively  develops  into  bronchial  respiration. 
Pulmonary  consolidation  either  from  compression  or  infiltration  is  the 
underlying  physical  condition  and  reaches  its  extreme  development  whether 
rapidly  or  slowly  by  progressive  advance. 

These  signs  are  heard  over  the  compressed  lung  in  the  following 
conditions:  pleural  effusion,  the  area  in  which  they  are  present  becom- 
ing more  limited  and  the  respiration  more  characteristically  bronchial 
as  the  effusion  augments;  pericardial  effusion;  pneumothorax,  in  which 
more  or  less  complete  compression  of  the  lung,  unless  prevented  by  old 
partial  adhesions,  takes  place  rapidly;  tumor  of  the  lung  or  pleura;  massive 
enlargement  of  the  heart,  and  large  aortic  aneurism.  They  are  heard  over 
the  lung  undergoing  solidification  or  already  solidified  from  infiltration  in 
tuberculosis,  bronchopneumonia,  croupous  pneumonia,  pulmonary  infarct. 
As  already  pointed  out,  distant  bronchial  breathing  may  frequently  be  heard 
over  an  effusion.  It  remains  to  point  out  the  more  important  fact  that 
loud,  distinct,  and  well-conducted  bronchial  respiration  is  by  no  means 
uncommon  over  pleural  effusions  of  large  amount  in  thin-walled  individuals 
and  especially  in  children.  This  sign  is  conducted  from  the  compressed 
lung  by  way  cf  the  wall  of  the  chest  and  probably  in  some  cases  also  along 
bands  of  old  adhesions  tightly  stretched  between  the  compressed  lung  and 
the  chest  wall  by  the  force  of  the  accumulating  fluid.  In  pneumothorax 
the  variety  of  bronchial  breathing  known  as  amphoric  is  heard  when  there 
is  free  communication  between  the  pleural  cavity  and  a  bronchus. 

Cavernous  or  amphoric  respiration  may  be  heard  over  cavities, 
whether  due  to  the  breaking  down  of  lung  tissue  (tuberculosis,  abscess, 
gangrene)  or  to  dilatation  of  bronchi  (bronchiectasis).  Deep-seated  cavi- 
ties due  to  any  of  these  causes  may  be  attended  with  distinct  bronchial 
respiration  yet  be  difficult  to  locate  with  precision. 

Bronchovesicular  respiration  must  be  distinguished  on  the  one  hand 
from  puerile  or  exaggerated  vesicular  respiration  and  on  the  other  from 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  167 

bronchial  respiration.  The  breezy  quality,  low  pitch,  short  expiratory 
element,  and  absence  of  a  period  of  silence  between  inspiration  and  expira- 
tion are  characteristic  of  the  former,  however  intense.  The  tubular  quality, 
relatively  high  pitch,  longer  expiratory  sound,  and  an  interval  of  silence 
are  distinctive  of  the  latter,  and  between  the  two  are  all  degrees  of  transi- 
tional sounds.  Normal  in  the  right  infraclavicular  region,  at  the  upper 
sternal  borders,  and  in  the  neighborhood  of  the  upper  dorsal  vertebrae, 
bronchovesicular  respiration  elsewhere  in  the  chest  becomes  a  sign  of 
disease,  and  denotes  partial  consolidation  of  the  lung,  patches  of  collapse 
or  infiltrated  lung  or  consolidation  with  intervening  normal  vesicular 
tissue.  This  sign  is  present  in  early  pulmonary  tuberculosis,  at  the  borders 
of  the  exudate  in  croupous  pneumonia,  in  bronchopneumonia,  and  in 
incomplete  atelectasis  from  any  cause. 

(c)   Adventitious     Sounds. — Purely    adventitious    respiratory    signs 
are  of  two  kinds:     (1)  Rales,  which  are  produced  by  abnormal  conditions- 
within  the  lungs,  and  (2)  friction  sounds  which  originate  in  the  pleura. 

1.  Rales. — Literally  a  rale  is  a  "rattle"  and  may  be  defined  as  an 
abnormal  respiratory  sound  heard  on  auscultation.  Rales  are  grouped  as 
dry  or  moist  according  to  the  impression  conveyed  to  the  mind  as  to  the 
presence  or  absence  of  fluid  in  the  mechanism  by  which  they  are  produced. 
They  are  laryngeal,  tracheal,  bronchial,  vesicular,  and  cavernous,  according 
to  the  situations  in  which  they  occur. 

In  general  rales  or  rhonchi  are  generated  in  the  air-passages  by  the 
ebb  and  flow  of  the  air  when  their  lumen  is  contracted  or  when  they  con- 
tain fluid — dry  and  moist  bronchial  rales.  Certain  rales  originate  in  the 
bronchioles  and  vesicular  structure  of  the  lung  (vesicular  rales),  others 
in  cavities  (gurgling),  and  finally  the  succussion  sound  and  the  sign  known 
as  gutta  cadens  or  metallic  tinkling  have  their  origin  in  hydropneumothorax. 
Rales  may  be  heard  upon  inspiration  or  expiration  or  during  both  acts. 
They  may  obscure  the  normal  breath  sounds  or  entirely  replace  them. 

Dry  rales  are  produced  by  stenosis  of  the  bronchial  tubes.  This 
narrowing  may  be  present  at  one  point  only  as  in  laryngeal  diphtheria  or 
oedema  of  the  glottis,  or  a  tumor  pressing  upon  the  trachea,  but  is  usually 
present  at  the  same  time  at  many  points  and  in  many  bronchial  tubes  of 
varying  diameter.  It  is  brought  about  by  a  variety  of  pathological  con- 
ditions, as  a  mass  of  tenacious  mucus  adherent  to  the  surface  of  the  tube, 
swelling  of  the  mucosa  or  submucosa,  spasmodic  coni  racl  ion  of  the  bronchial 
musculature,  and  the  external  pressure  of  enlarged  glands  or  a  tumor. 
When  this  narrowing  involves  the  smaller  bronchial  tubes  the  rales  which 
result  are  high  pitched— sibilant;  when  it  affects  the  larger  tubes  the 
rales  are  low  pitched — sonorous.  They  resemble  the  cooing  of  cloves,  the 
hissing  of  geese,  and  have  very  often  a  musical  quality.  Sometimes  they 
are  groaning  or  squeaking.  In  asthma  they  are  often  heard  in  great  variety 
of  size,  pitch,  intensity,  and  quality,  both  upon  inspiration  and  expiration, 
and  appear  and  disappear  with  the  most  remarkable  modifications  and 
great  rapidity. 

Moist  rales  are  caused  by  the  passage  of  air  through  the  bronchi 
when  they  contain  fluid — mucus,  pus,  blood.  The  mechanism  consists  in 
the  presence  of  bubbles  or  diaphragms  before  the  incoming  and  out  going  air 


168  MEDICAL  DIAGNOSIS. 

which  continuously  burst  and  reform.  When  this  process  takes  place  in 
the  larger  tubes,  the  bubbles  are  large  and  the  rales  coarse  or  large  bubbling; 
when  in  the  smaller  tubes,  they  are  finer,  small  bubbling  or  subcrepitant 
rales.  Large  moist  rales  are  usually  low  in  pitch;  small  moist  rales  higher, 
and  in  this  respect  moist  and  dry  rales  correspond.  The  tracheal  rale  or 
death-rattle  is  an  example  of  a  very  coarse  rale;  the  small  moist  or  sub- 
crepitant rale  heard  in  bronchopneumonia  in  both  respiratory  acts  is  an 
example  of  a  fine  moist  rale. 

Both  dry  and  moist  rales  vary  in  intensity  and  locality.  The  extent 
of  the  area  over  which  they  are  heard  depends  upon  that  of  the  process 
by  which  they  are  caused;  their  acoustic  characters  upon  the  physical 
changes  produced  by  that  process.  In  bronchitis  rales  are  very  often  best 
heard  at  the  bases  of  the  lungs  posteriorly;  in  tuberculous  disease  of  an 
apex,  in  the  subclavicular  region.  Rales  are  very  often  influenced  by  the 
act  of  coughing  and  expectoration.  Dry  rales  produced  by  pressure  steno- 
sis, tenacious  exudate  which  cannot  be  dislodged,  or  bronchial  spasm,  do 
not  disappear  upon  coughing. 

Vesicular  or  crepitant  rales  originate  in  the  finest  bronchioles  and 
air-cells.  Notwithstanding  the  differences  of  view  in  regard  to  the  mechan- 
ism by  which  they  are  produced,  the  weight  of  evidence  is  still  in  favor  of 
the  theory  that  it  is  by  the  inspiratory  separation  of  the  walls  of  terminal 
structures — bronchioles,  alevoli — previously  collapsed  or  held  together  by 
a  thin  layer  of  sticky  exudate  or  serum.  In  support  of  this  theory  the 
following  facts  may  be  adduced:  This  rale,  at  one  time  held  to  be  pathog- 
nomonic of  croupous  pneumonia,  is  now  known  to  occur  also  in  other 
pathological  conditions  in  which  an  exudate  or  blood  is  present  in  the 
lung  parenchyma,  as  pulmonary  eedema,  hemorrhagic  infarct,  and  acute 
pneumonic  phthisis.  It  is  common  in  partial  atelectasis— atelectatic 
crepitation  of  Abrams.  Crepitant  rales  sometimes  associated  with  sub- 
crepitant rales  are  frequently  heard  during  deep  inspiration  at  the  bases 
of  the  chest  posteriorly  and  laterally  in  persons  whose  respiration  is  habitu- 
ally shallow.  This  is  not  only  the  case  in  bed-ridden  individuals  but  also 
in  many  healthy  persons,  especially  after  middle  age.  The  crepitant  rale 
is  heard  only  upon  inspiration.  The  subcrepitant  rale  with  which  it  is 
often  associated  is  usually  coarser  and  slightly  moist. 

The  crepitant  rale  is  usually  heard  towards  the  end  of  inspiration; 
the  individual  rales  are  of  the  same  size  and  intensity  and  they  often 
occur  in  "showers,"  a  large  number  of  single  sounds  having  the  same 
acoustic  properties  following  each  other  in  rapid  and  irregular  succession. 

The  crepitant  rale  occurs  in  croupous  pneumonia  at  the  beginning  of 
the  process, —  crepitus  indux,- — disappears  when  the  exudate  undergoes 
coagulation,  and  reappears  together  with  subcrepitant  rales  when  the 
exudate  undergoes  liquefaction  and  resorption,  —  crepitus  redux.  This 
auscultatory  sign  may  be  imitated  by  placing  a  little  mucilage  between 
the  finger  and  thumb  and  making  repeated  contact  and  separation.  With 
contact  there  is  no  sound,  but  upon  separating  the  thumb  and  finger  a 
string  of  tenacious  mucilage  is  drawn  out  which  finally  snaps  with  a  sharp 
sound  not  unlike  the  rale.  It  may  also  be  imitated  by  the  crackling  of 
fine  salt  thrown  upon  the  fire,  the  creaking  of  a  silk  garment,  or  lightly 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  169 

rubbing  a  few  strands  of  hair  between  the  thumb  and  finger.  If  the  stetho- 
scope is  applied  over  the  thick  growth  of  coarse  hair  found  upon  the  chest 
of  many  men,  a  sound  closely  resembling  crepitation  will  be  heard.  Crack- 
ling is  the  term  used  technically  to  designate  a  rale  coarser  than  crepitus 
but  having  in  other  respects  similar  acoustic  properties.  This  rale  consists 
of  a  limited  number  of  well-defined  sharp  crackling  sounds  often  heard  in 
beginning  pulmonary  tuberculosis  or  at  the  borders  of  an  advancing  tuber- 
culous lesion  and  for  this  reason  is  of  considerable  diagnostic  importance. 
The  distinction  between  crepitus  and  crackling  is  not  always  unattended 
with  difficulty.  Crepitus  consists  of  a  number  of  fine  sounds,  heard  only 
upon  inspiration  and  often  over  a  considerable  area  at  the  base  of  the 
lung;  crackling  of  a  few  sharp,  well-defined,  rather  coarser  sounds  heard  also 
in  inspiration  but  over  a  limited  area  and  commonly  at  the  apex.  It  is 
probable  that  the  mechanism  is  the  same  in  both,  but  that  crackling  occurs 
in  limited  lesions,  hence  only  a  few  individual  sounds  are  heard;  in  wider 
spaces,  terminal  bronchi,  hence  the  sounds  are  coarser;  and  at  a  point 
surrounded  by  densely  consolidated  tissue,  hence  they  are  better  conducted 
to  the  ear — consonating  rales.  Moist  crackling  and  clicking  are  varieties  of 
crackling  which  are  regarded  as  indicative  of  softening  tubercle.  In  certain 
cases  of  dry  or  plastic  pleurisy  fine  dry  friction  sounds  are  to  be  heard  which 
can  scarcely  be  distinguished  from  subcrepitant  rales.  If  they  occur  only 
upon  inspiration  they  may  be  mistaken  for  crepitus. 

Gurgling  or  the  rale  of  cavities  is  caused  by  the  entrance  and  exit 
of  air  in  a  cavity  containing  fluid.  «  Coarse  churning  sounds  are  heard  resem- 
bling those  produced  by  pouring  fluid  rapidly  from  a  bottle.  These  very 
coarse,  well-defined  rales  are  known  also  as  cavernous,  and  sometimes 
have  the  metallic  or  amphoric  quality. 

Metallic  Tinkling — GuttaCadens. — All  rales  heard  in  pneumothorax 
acquire  the  amphoric  or  metallic  quality.  In  some  instances  single  rales 
having  an  exquisite  metallic  or  bell-like  musical  quality  may  follow  deep 
inspiration  or  the  act  of  coughing.  This  sound,  which  resembles  that  made 
by  single  fine  shot  dropped  into  a  metal  bowl  or  basin,  was  at  one  time 
thought  to  be  caused  by  a  drop  of  exudate  or  pus  collecting  at  the  vault 
of  the  cavity  and  falling  upon  the  surface  of  the  fluid  collected  at  its  base. 
It  is  now  known  that  it  may  occur  in  the  absence  of  any  such  collection 
of  fluid  and  that  it  may  lie  due  to  the  bursting  of  a  bubble  formed  at  the 
pleural  orifice  of  a  bronchopulmonary  fistula. 

Hippocratic  Suc<  i  ssion.— This  phenomenon,  although  il  is  not  anile 
in  the  narrow  Bense,  may  be  best  described  at  this  point.  It  is  character- 
istic of  hydro-  (pyo-haemo-)  pneumothorax  and  consists  of  a  distinct  loud 

splashing  which  may  be  heard  and  felt  when  t  he  t  horax  is  suddenly  shaken. 
It  is  due  to  1  he  swash  of  t  he  free  fluid  against   t  he  wall  of  the  chest .  JUSl  as  a 

similar  sound  is  produced  by  the  sudden  movement  of  a  partially  filled  cask. 
'I'm:  Bronchopulmonari  Fistula  Rale,  [n  hydro-  or  pyopneumo- 
t  horax.  when  t  he  accumulating  fluid  rises  above  the  pleura]  opening  of  the 
fistula  there  may  be  sometimes  heard  in  connection  with  paroxysmal 
cough  bubbling  sounds  due  to  inspired  air  being  forced  from  the  lung  and 
up  through  the  fluid.     Under  such  circumstances  violent   spells  of  cough 

are  apt    to  be   followed    by   copious  expectoration. 


170  MEDICAL   DIAGNOSIS. 

Rales  may  be  conveniently  grouped  as  follows: 

,  _  _„,       .        fLow  pitched — Sonorous. 

Dry  or  Vibrating  ]  ffigh  pitched_Sibilant. 

Bronchial  Rales  i 

I  Moist  or  Bubbling -f  ^rge  bubbling-Mucous. 

(Small  bubbling — Subcrepitant. 

Vesicular  Rales  {  Crepitus. 

( Crackling  (Clicking). 

The  Rale  of  Cavities  \  Jer*  Coarse  Bubbling-Gurgling. 
(  Cavernous  and  Amphoric  Rales. 

{Metallic  Tinkling — Gutta  Cadens. 
The  Bronchopulmonary  Fistula  Rale. 
The  Hippocratic  Succussion. 

2.  Friction  Sounds. — The  surfaces  of  the  normal  pleura,  being  moist 
and  smooth,  glide  noiselessly  over  one  another  with  the  movements  of  respi- 
ration. When,  however,  the  serous  membrane  is  roughened  by  the  presence 
of  a  fibrinous  exudate,  as  in  pleurisy,  the  movement  of  the  opposed  surfaces 
gives  rise  to  sounds  known  as  "pleural  friction  sounds"  or  "friction  rubs." 
As  the  lesions  of  pleurisy  vary  from  a  mere  dryness  of  the  surface  in  the 
beginning  to  every  grade  of  exudate  in  amount,  texture,  and  arrangement, 
including  the  fibrinoserous  forms,  so  the  friction  sounds  present  great 
diversity  in  their  acoustic  properties,  not  only  in  different  cases  but  also 
in  the  same  case  during  its  course. 

The  general  and  almost  constant  character  of  pleural  friction  is,  how- 
ever, that  of  the  sounds  pi  oduced  by  the  rubbing  together  of  dry  or  slightly 
moistened  surfaces,  and  is  properly  characterized  as  grazing,  rubbing, 
creaking,  leathery,  grating,  rasping,  and  the  like.  Friction  sounds  are 
usually  jerky  and  irregularly  interrupted,  and  change  in  character  not 
only  in  the  course  of  time  but  even  in  the  course  of  a  single  respiratory 
act.  They  are  superficial  and  give  the  impression  of  being  produced  very 
near  the  ear.  They  vary  in  intensity  from  a  mere  graze,  scarcely  audible, 
to  a  coarse,  loud,  and  prolonged  creaking  like  that  of  new  leather  and 
audible  to  the  patient  himself  or  the  bystanders.  They  are  described  as 
fine,  medium,  or  coarse.  They  are  as  a  rule  best  heard  and  often  only  heard 
in  the  infra-axillary  or  inframammary  region  where  the  respiratory  excursus 
is  widest  and  the  pleura  investing  the  thin  wedge  of  lung  is  in  contact 
upon  one  side  with  the  costal  and  upon  the  other  with  the  diaphragmatic 
pleura.  Not  being  well  conducted,  they  are  heard  where  they  are  produced, 
so  that  in  cases  of  diaphragmatic  pleurisy  the  friction  sounds  may  be  heard 
below  the  level  of  the  lung,  in  croupous  pneumonia  opposite  the  seat  of 
the  exudate,  and  in  the  earliest  days  of  phthisis  at  the  apex.  They  may 
sometimes  be  heard  over  the  entire  lung  from  the  apex  to  the  base.  In 
children  and  spare  persons  the  intensity  of  these  sounds  may  be  increased 
by  firm  pressure  upon  the  chest,  and  they  are  often  attended  by  a  palpable 
sign — friction  fremitus.  They  occur  most  commonly  during  inspiration  and 
especially  toward  the  end  of  the  act,  and  are  frequently  heard  also  during 
expiration.    Less  often  they  are  present  during  expiration  alone. 

Friction  sounds  are  sometimes  inconstant,  ceasing  after  several  deep 
inspiratory  acts  and  being  again  heard  after  a  period  of  quiet  breathing. 
They  are  not  modified,  however,  to  the  same  extent  as  rales,  nor  do  they 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  171 

disappear  upon  coughing  and  the  expectoration  of  mucus.  Various  pos- 
tural methods  of  bringing  out  friction  sounds  in  suspected  cases  have  been 
described,  as  raising  the  arm  upon  the  affected  side  or  having  the  patient 
quickly  rise  from  the  recumbent  to  the  sitting  posture  during  held  expira- 
tion and  then  take  a  very  deep  inspiration. 

Deep  breathing,  coughing,  pressure  upon  the  affected  side,  not  only 
increase  the  intensity  of  the  sounds,  but  are  also  attended  with  pain.  In 
exceptional  cases  friction  sounds  are  unattended  by  pain  during  these  acts. 
When  a  plastic  pleurisy  is  followed  by  a  serofibrinous  exudate  the  friction 
sounds  disappear,  but  recur  upon  the  resorption  or  removal  of  the  fluid. 
They  are  usually  present  upon  one  side  of  the  chest  only,  but  may  some- 
times, especially  in  disseminated  tuberculosis,  be  heard  in  circumscribed 
areas  on  both  sides. 

Crumpling  friction  sounds  are  the  signs  of  acute  inflammation  of  the 
pleura.  When  the  process  subsides  the  surfaces  become  fused,  the  fibri- 
nous exudate  organized.  The  condition  is  that  of  adherent  pleura  and, 
unless  dense  and  extensive,  does  not  give  rise  to  physical  signs.  In  old 
pleurisy  at  the  apex  and  especially  when  cavities  exist,  curious,  low- 
pitched,  soft,  creaking  sounds  are  sometimes  heard.  This  sound  resembles 
that  produced  by  squeezing  soft  thick  paper  together  in  the  hand  in 
irregular  folds  and  is  described  as  crumpling.  It  is  present  upon  inspira- 
tion and  expiration  and  is  not  affected  by  cough,  nor  has  it  the  characters 
by  which  we  recognize  rales. 

In  some  cases  of  pleural  effusion  a  considerable  period  elapses  between 
the  resorption  of  the  fluid  and  the  formation  of  adhesions.  During  this 
time  friction  sounds  may  be  heard  and  the  patient  may  experience  annoying 
grating  or  rubbing  sensations,  especially  upon  deep  breathing  or  coughing. 

Sounds  closely  simulating  friction  sounds  may  be  produced  by  rubbing 
the  thumb  and  finger  together  near  the  ear  or  by  holding  the  hollow  of  the 
hand  over  the  ear  and  rubbing  or  stroking  the  back  of  it  with  the  fingers 
of  the  other  hand.  There  is  a  fine  friction  sound  which  cannot  be  dis- 
tinguished from  crepitus.  Both  occur  in  showers  at  the  end  of  inspiration, 
both  are  close  to  the  ear  and  have  the  same  acoustic  qualities,  both  are 
accompanied  by  an  expiratory  element  which  may  be  in  one  case  a  fric- 
tion sound  and  in  the  other  a  subcrepitant  rale.  By  the  sound  itself  the 
differentiation  is  impossible,  but  when  concomitant  phenomena  are  taken 
into  account  we  find  the  friction  sound  is  usually  more  limited  in  extent, 
attended  more  commonly  by  expiratory  sounds,  is  less  uniform  in  charac- 
ter, and  disappears  when  the  movement  of  the  chest  wall  is  restricted  by 
compression,  while  crepitus  persists.  The  distinction  between  fine  friction 
of  this  form  and  the  crepitant  rale  or  crackling  is  rather  of  theoretical  than 
practical  importance  when  we  reflect  that  in  pneumonia,  when,  as  is  com- 
monly the  case,  the  exudate  extends  to  the  periphery  of  the  lung,  the 
pleura  overlying  it  is  the  seat  of  an  inflammatory  exudate,  and  in  tuber- 
culosis of  the  apex  the  early  lesions  which  give  rise  to  creaking  are  accom- 
panied by  a  circumscribed  pleurisy.  In  point  of  fact  when  we  hear  one  of 
these  signs  the  other  usually  is  also  present. 

The  friction  sound  which  closely  resembles  crepitus  or  crackling  is 
very  rarely,  if  ever,  heard  in  simple,  uncomplicated  pleurisy. 


172  MEDICAL  DIAGNOSIS. 

Friction  sounds  heard  over  the  chest  are  significant  of  pleurisy.  Those 
over  the  precordial  space,  having  the  cardiac  rhythm,  are  usually  but  not 
invariably  signs  of  pericarditis.  The  subject  of  pericardial  and  pleuro- 
pericardial  friction  will  engage  our  attention  in  a  subsequent  section. 
Friction  sounds  heard  in  the  epigastric  zone  constitute  in  rare  instances 
the  signs  of  a  peritonitis.  The  effusion  in  hyclrothorax  is  not  preceded 
by  a  friction  sound.  Pleurisj'  is  frequently  primary;  often  secondary  to 
intrapulmonary  disease,  pneumonia,  tuberculosis,  cirrhosis  of  the  lung, 
abscess,  gangrene,  or  cancer;  and  sometimes,  especially  upon  the  right 
side,  secondary  to  subdiaphragmatic  disease,  as  abscess,  cancer  or  hyda- 
tids of  the  liver,  or  subphrenic  abscess.  Friction  sounds  may  therefore  be 
significant  of  any  of  these  affections. 

Riesman  has  described  under  the  term  subpleural  friction  a  fine  soft 
rubbing  or  crepitation  which  occurs  in  the  absence  of  pain  or  the  signs  of 
consolidation  in  miliary  tuberculosis.  The  difficulty  in  distinguishing  fine 
pleural  friction  from  crepitus  has  already  been  discussed. 

AUSCULTATION    DURING   PHONATION. 

Auscultation  of  the  Voice  in  Health  and  Disease. — The  sounds  heard 
upon  auscultation  of  the  chest  of  a  person  who  is  speaking  when  the  face 
of  the  patient  is  turned  away  or  the  opposite  ear  of  the  examiner  closed, 
or  when  the  binaural  stethoscope  is  employed,  constitute  the  set  of  physi- 
cal signs  comprised  under  the  general  term  vocal  resonance,  and  have 
diagnostic  value.  The  ordinary  spoken  and  the  whispered  voice  are  studied. 
Obstacles  to  the  employment  of  this  method  of  physical  diagnosis  consist 
in  want  of  cooperation,  as  in  children  and  extremely  ill  persons,  in  inability 
to  use  the  voice,  as  in  mutes,  those  suffering  from  aphonia  from  any  cause, 
and  in  extremely  feeble^  patients  and  great  obesity. 

The  Technic. — The  patient  counts  in  a  monotone,  turns  his  face  away 
and  counts  ' '  one,  two,  three  " ;  or  repeats  ' '  twenty-one  "  or  "  ninety-nine ' '  in 
the  loud  voice  or  in  a  stage  whisper.  The  sound  is  conducted  through  the 
bronchi  and  along  their  walls  in  the  same  manner  as  in  a  speaking  tube 
and  greatly  dispersed  and  damped  in  the  cushiony  vesicular  tissue.  Changes 
in  the  physical  condition  of  the  lung  parenchyma  favor  or  still  further 
impede  the  transmission  of  the  voice  in  such  a  manner  that  increase,  diminu- 
tion, or  absence  of  vocal  resonance  correspond  to  these  changes  and  thus 
become  signs  of  disease.  The  modifications  of  vocal  resonance  correspond  in 
general  to  those  of  vocal  fremitus  and  have  the  same  significance. 

Normal  Vocal  Resonance. — The  voice  is  heard  as  a  confused  inarticu- 
late hum,  most  distinct  in  adults  possessed  of  deep  voices  and  tremulous 
in  aged  persons.  This  sound  is  more  intense  upon  the  right  than  upon  the 
left  side  and  at  the  apices  than  at  the  base.  As  the  stethoscope  is  carried 
to  a  position  nearer  the  main  bronchi  the  resonance  becomes  louder  and 
more  distinct  until  finally,  when  it  is  placed  over  the  bronchi  or  trachea 
in  the  position  in  which  normal  bronchial  breathing  is  heard,  the  audible 
words  may  be  recognized — bronchophony. 

Increased  Vocal  Resonance. — This  sign  when  heard  over  the  lung — 
with  rare  exceptions,  presently  to  be  mentioned — denotes  an  increase  in 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  173 

the  power  of  the  lung  to  conduct  sound-producing  vibrations, — namely, 
consolidation.  It  has,  therefore,  the  same  significance  as  bronchial  respi- 
ration. Fully  developed  it  constitutes  bronchophony,  and  indicates  con- 
solidation of  lung  tissue  in  the  neighborhood  of  large  or  medium-sized 
bronchial  tubes.    The  following  varieties  are  to  be  considered: 

Pectoriloquy. — Laennec  used  this  term  to  indicate  the  complete  trans- 
mission of  articulate  words.  The  voice  appears  to  be  directly  spoken  into 
the  observer's  ear.  This  sign  occurs  in  dense  consolidation  extending  from 
a  large  bronchus  to  the  wall  of  the  chest,  over  a  cavity  communicating 
freely  with  a  bronchus  of  some  size,  in  a  pneumothorax  communicating 
with  a  bronchus,  and  in  some  instances  over  the  atelectatic  lung  over- 
lying a  large  pleural  effusion.  When  pectoriloquy  is  very  distinct  and 
circumscribed  it  constitutes  the  distinct  physical  sign  of  a  cavity,  and, 
as  Da  Costa  well  said,  deserves  the  name  of  cavernous  voice. 

Amphoric  Vocal  Resonance.  —  Over  large  cavities  and  in  pneumo- 
thorax communicating  with  a  bronchus  the  voice  is  peculiarly  ringing  and 
metallic.  The  amphoric  character  is  due  to  the  same  physical  conditions 
which  we  find  to  underlie  the  amphoric  quality  in  the  breath  sounds  and  rales. 
Whispering  Pectoriloquy. — The  whispered  voice  is  heard  as  a  faint, 
distant,  expiratory  whiff  or  puff  over  the  trachea  and  primary  bronchi  in 
front  and  behind  while  elsewhere  it  is  almost  or  quite  inaudible.  When 
the  physical  conditions  which  cause  bronchophony  are  present,  the  whisp- 
ered voice  is  curiously  near  and  distinct.  Whispering  pectoriloquy  is  an 
important  physical  sign,  indicating,  when  distinct  and  circumscribed,  a 
cavity,  and  in  varying  degrees  of  intensity  consolidation  of  lung  tissue.  It 
is  of  value  in  the  diagnosis  of  limited  areas  of  consolidation  and  in  determining 
the  boundaries  of  large  ones.  The  more  dense  the  consolidation  the  more 
distinct  the  whispered  voice.  Whispering  pectoriloquy  may  be  present  over 
the  atelectatic  lung  in  pleural  effusion  and  occasionally  over  the  effusion 
itself.  Increased  whisper  in  the  intrascapular  regions — D'Espine's  sign — 
occurs  in  tuberculosis  of  the  bronchial  glands. 

Diminished  Vocal  Resonance.  —  This  sign  indicates  impaired  con- 
duction in  the  lung  and  is  present  in  emphysema  and  the  occlusion  of  a 
bronchus.  It  also  denotes  the  interposition  of  substances  between  the 
lung  and  the  chest  wall,  which  leads  to  the  diffusion  and  weakening  of 
vibrations  passing  from  one  medium  to  another,  and  occurs  in  pleural 
effusion,  pleural  thickening,  and  tumors.  The  more  massive  the  effusion. 
the  greater  the  thickening,  or  the  larger  the  tumor,  the  more  marked  the 
diminution  in  the  transmitted  voice  resonance.  It  may  be  completely 
absent  in  closed  pneumothorax.  Absent  vocal  resonance  is  most  common 
in  large  pleural  effusion. 

/Egophony.  Literally,  the  bleating  of  a  goat.  A  peculiar  quavering 
quality  of  the  voice  with  a  distinctly  nasal  tone  is  heard  when  the  patient 
speaks  in  a  natural  voice.  This  sign  is  best  brought  out  by  using  repeated 
rather  than  single  syllables,  as  "  t  went  y-one  "  or  "  ninet  y-nine.  "  It  may  be 
heard  at  or  just  below  the  upper  limit  of  moderate-sized  pleural  effusions 
in  the  region  of  the  angle  of  the  scapula;  less  frequently  in  the  front  of  the 
chest.  It  is  in  rare  instances  heard  over  consolidated  lung  tissue.  It  is 
not  an  import ani   physical  sign. 


174  MEDICAL    DIAGNOSIS. 

Baccelli's  Sign. — Upon  direct  auscultation  in  the  anterolateral  region 
of  the  affected  side  the  whispered  voice  is  said  to  be  distinctly  transmitted 
through  a  serous  but  not  through  a  purulent  effusion,  the  difference  being 
attributed  to  variations  in  the  density  of  serofibrinous  and  purulent  effu- 
sions. This  sign  is  not  constant,  since  in  large  effusions  there  is  commonly 
absence  of  vocal  resonance  in  both  kinds  of  fluid. 

Auscultation   as  Applied  to  the   Diagnosis  of  Diseases 
of  the  Circulatory  Organs. 

The  Technic. — This  method  is  of  cardinal  importance  in  the  examina- 
tion of  the  heart.  Upon  it  in  most  instances  the  diagnosis  depends. 
Inspection,  palpation,  and  percussion  may  be  used  to  amplify  and  control 
the  signs  obtained  by  auscultation,  but  in  a  considerable  proportion  of 
the  cases  they  contribute  no  essential  facts.  Before  we  apply  the  stetho- 
scope, we  inquire  into  the  history  of  the  case  and  place  the  patient  as  far 
as  possible  at  his  ease.  The  examination  is  best  conducted  when  the  patient 
is  in  a  comfortable  position,  leaning  back  in  a  chair  or  propped  up  with 
pillows  in  bed.  We  note  the  facial  expression,  the  appearance  of  the 
eyes,  the  state  of  the  capillary  circulation,  the  presence  or  absence  of 
dropsical  swellings,  whether  or  not  there  is  cough,  the  character  of  the 
respiration  and  any  abnormal  impulse  or  movement  that  may  be  present 
at  the  root  of  the  neck  or  in  the  chest.  The  signs  elicited  upon  inspec- 
tion, palpation,  and  percussion  are  then  ascertained.  Finally  we  employ 
auscultation. 

In  women  the  breast  is  drawn  aside  and  held  by  the  patient  herself 
or  her  nurse.  In  young  children  inspection  and  palpation  should  precede 
auscultation.  Percussion  is  useless.  Very  often  the  auscultatory  signs 
must  be  caught  in  the  intervals  of  crying  and  struggling.  Many  difficulties 
may  be  overcome  by  ta'ct  and  gentleness. 

The  increase  in  the  frequency  of  the  heart's  action  and  the  accom- 
panying change  in  the  character  of  the  first  sound  that  occur  in  nervous 
persons  under  examination  (le  coeur  medical)  must  be  borne  in  mind.  A 
few  minutes'  chat  upon  indifferent  subjects  will  usually  cause  the  excited 
action  to  subside.  If  on  the  other  hand  the  action  of  the  heart  is  weak 
and  the  sounds  too  faint  to  be  well  studied,  or  there  is  a  doubt  as  to  the 
presence  of  a  murmur,  the  patient  should  be  asked,  unless  his  general  con- 
dition forbids,  to  take  a  series  of  very  deep  breaths,  or  quickly  stoop  and 
rise  several  times,  or  take  a  few  brisk  turns  up  and  down  the  room.  The 
increase  in  the  force  of  the  heart's  action  will  often  render  the  sounds 
distinct  and  dispel  any  doubt  as  to  the  presence  of  a  murmur.  In  cases 
of  acute  disease  or  profound  general  or  cardiac  asthenia  such  diagnostic 
measures  are  strictly  contraindicated. 

Faint  and  distant  sounds  and  obscure  murmurs  may  become  more 
audible  if  the  patient  leans  slightly  forward  and  to  his  left,  thus 
bringing  the  heart  under  the  influence  of  gravity  into  closer  relation 
with  the  wall  of  the  chest.  It  is  important  also  to  request  the  patient 
to  stop  breathing  for  a  moment  now  and  again  during  the  course  of  the 
examination,  since  the  breath  sounds  may  mask  the  normal  and  abnormal 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION. 


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176  MEDICAL  DIAGNOSIS. 

sounds  of  a  feeble  heart.     The  heart  sounds  should  also  be  studied  with 
full  held  inspiration  and  forced  expiration. 

Auscultation  has  for  its  object  the  determination  of  the  character, 
intensity,  and  rhythm  of  the  normal  heart  sounds,  and  their  modifications 
within  the  range  of  health,  the  recognition  of  modifications  which  tran- 
scend those  limits,  and  the  detection  of  abnormal  or  adventitious  sounds. 

THE  SIGNS  IN  HEALTH. 

The  Normal  Heart  Sounds. — When  the  stethoscope  is  placed  over 
the  heart  two  sounds  are  heard.  Of  these  one  is  found  to  correspond 
in  time  with  the  cardiac  impulse,  and  the  other  to  follow  it  after  a  short 
interval  of  silence.  After  a  longer,  but  still  short  interval,  these  sounds 
are  repeated  in  the  same  order.  For  this  reason  they  are  spoken  of  re- 
spectively as  the  first  and  second  sound  of  the  heart. 

The  Characters  of  the  Sounds. — The  first  sound  is  not  only  compara- 
tively long,  but  it  is  also  low  in  pitch  and  muffled.  The  second  sound, 
on  the  contrary,  is  comparatively  short  and  is  high  pitched  and  clear.  The 
two  sounds  are  therefore  in  sharp  contrast  in  regard  to  their  duration, 
pitch,  and  quality.  The  respective  characters  of  the  two  sounds  may  be 
roughly  imitated  by  the  repetition  of  the  syllables  "  ubb  dwp. " 

Causes  of  the  First  Sound.  —  The  first  sound  is  due  to  vibrations 
caused  by  the  simultaneous  tension  of  the  mitral  and  tricuspid  valves 
in  closure,  the  muscular  contraction  of  the  ventricles  and  the  vibration 
of  the  blood  contained  within  the  ventricles  at  the  moment  of  systole. 

The  Cause  of  the  Second  Sound. — The  second  sound  is  due  to  the  vibra- 
tions caused  by  the  simultaneous  closure  of  the  semilunar  valves  of  the 
pulmonary  artery  and  the  aorta  at  the  beginning  of  the  ventricular  diastole. 

A  Third  Sound  of  the  Heart. — Gibson  has  recently  described  a  wave 
in  the  jugular  pulse  in  healthy  young  adults  occurring  after  the  clos- 
ure of  the  semilunar  valves  and  before  the  auricular  contraction,  and 
accompanied  by  a  low-pitched,  clear  sound  at  the  apex,  more  distinctly 
audible  in  the  cardiac  revolutions  which  occur  in  the  intervals  between 
expiration  and  inspiration  than  at  any  other  stages  of  respiration.  This 
sound  is  not  easily  appreciated  and  is  only  audible  in  a  certain  propor- 
tion of  the  diastolic  periods.  It  corresponds  in  time  to  the  first  element 
of  the  reduplicated  second  sound  heard  only  at  the  apex,  long  familiar 
to  clinicians.  The  explanations  of  this  sound  are  at  present  purely 
hypothetical. 

The  Cardiac  Cycle  or  Revolution. — Each  revolution  of  the  heart 
consists  of  an  auricular  systole,  the  instantly  succeeding  ventricular  systole, 
and  a  period  of  repose  of  the  whole  heart.  The  relative  time  occupied 
with  these  events  varies  with  the  frequency  of  the  action  of  the  heart. 
With  a  pulse-rate  of  74,  that  is,  a  cardiac  revolution  of  about  0.8  second, 
the  cardiac  revolution  comprises  an  auricular  systole  of  0.1  second,  a 
ventricular  systole  of  0.3  second,  and  a  period  of  repose  of  the  whole  heart 
of  0.4  second.  With  increased  pulse-frequency  the  diastole  of  the  ven- 
tricles is  shortened  much  more  than  the  systole;  it  is  also,  with  slowing 
of  the  pulse-rate,  lengthened  to  a  greater  extent.     The  statements  which 


PHYSICAL  DIAGNOSIS:    AUSCULTATION.  177 

assign  regular  proportions  to  the  duration  of  the  sounds  and  silences  of 
the  heart  are  misleading,  since  these  vary  in  length,  not  relatively  with 
varying  heart  frequency,  but  absolutely,  the  second  silence  being  very 
fluctuating,  since  it  corresponds  to  the  fluctuating  ventricular  diastole, 
while  the  first  sound  and  the  short  first  silence  together,  which  nearly 
correspond  to  the  ventricular  systole,  are  much  more  constant. 

The  Valve  Areas  or  Puncta  Maxima. — With  the  stethoscope  applied 
over  the  apex  of  the  heart  the  first  sound  is  heard  much  more  distinctly 
than  the  second  sound  and  has  a  booming  character  which  is  in  sharp 
contrast  with  the  short  and  "valvular"  quality  of  the  latter.  The  temp- 
tation to  rely  upon  the  rhythm  of  the  sounds  for  the  recognition  of  the 
systolic  sound  or  the  first  and  second  sounds  is  to  be  avoided.  The  aus- 
cultatory sign  must  be  verified  by  inspection  or  palpation.  This  is  espe- 
cially important  in  the  rapidly  acting  heart  and  in  all  morbid  conditions. 
The  systolic  or  first  sound  corresponds  to  the  impulse  as  determined  by 
sight  or  touch,  or  in  default  of  these  by  the  pulsation  of  the  carotid.  The 
radial  pulse  cannot  be  depended  upon  as  a  guide.  The  recognition  of 
the  first  and  second  sounds  is  of  especial  importance  in  the  diagnosis  of 
valvular  diseases. 

When  the  stethoscope  is  carried  to  the  base  of  the  heart,  either  to  the 
right  or  the  left  border  of  the  sternum,  the  first  sound  becomes  less  distinct 
than  at  the  apex  while  retaining  its  acoustic  properties,  and  the  second  sound 
more  distinct  and  prominent  with  an  intensification  of  its  snapping  or 
valvular  quality. 

The  sounds  may  be  further  analyzed  by  placing  the  stethoscope  at 
the  following  principal  points  or  areas: 

1.  The  Mitral  Area. — At  or  above  the  apex  in  the  fifth  intercostal 
space  and  upon  the  parasternal  line.  At  this  point  that  factor  of  the  first 
sound  made  up  by  the  closure  of  the  mitral  valve  and  the  contraction  of 
the  left  ventricle  is  best  heard. 

2.  The  Tricuspid  Area. — At  the  juncture  of  the  ensiform  cartilage  with 
the  sternum  and  at  the  right  border  of  the  base  of  the  sternum.  In  this 
region  that  factor  of  the  first  sound  caused  by  the  closure  of  the  tricuspid 
valve  and  the  contraction  of  the  right  ventricle  is  most  distinctly  heard. 

3.  The  Aortic  Area. — In  the  second  right  intercostal  space  near  the 
sternum  or  directly  over  the  second  right  costal  cartilage  at  its  sternal 
articulation — the  aortic  cartilage.  At  this  point  the  aortic  element  of 
the  second  sound  is  best  heard. 

4.  The  Pulmonary  Area.— In  the  second  loft  intercostal  space  near 
the  sternal  border.  At  this  point  the  pulmonary  element  of  the  second 
sound   is   best    appreciated. 

These  areas  do  not  correspond  to  the  position  of  the  respective  valve 
systems,  but  they  do  correspond  to  the  anatomical  relationship  to  the 
wall  of  the  chest  of  the  structure  in  which  the  mechanism  producing 
the  sound  exists,  or  in  which  the  sound  is  conducted.  That  is  to  say.  the 
anatomical  apex  of  the  heart  formed  by  the  left  ventricle  comes  nearest 
to  the  chest  at  the  apex;  the  tricuspid  valve  system  at  the  ripht  border 
and  base  of  the  sternum;  the  aorta  just  above  its  origin  at  the  second 
right  interspace,  and  the  pulmonary  artery  above  its  valves  nt  the  second 
left  interspace. 
12 


178  MEDICAL  DIAGNOSIS. 

At  the  apex  the  first  sound  and  its  modifications  in  health  and  disease 
are  best  studied;  at  the  base  the  second  sound.  In  the  former  position 
this  first  sound  is  louder  and  more  distinct;  in  the  latter  the  rhythm  is 
changed  and  the  stress  falls  upon  the  second  sound.  The  rhythm  is  the 
same  in  the  mitral  and  the  tricuspid  areas  and  the  quality  of  the  first 
sound  is  similar,  though  in  health  the  first  sound  is  usually  less  intense 
in  the  tricuspid  area.  The  rhythm  is  likewise  the  same  in  the  aortic  and 
the  pulmonary  areas,  and  the  quality  of  the  second  sound  is  similar  upon  the 
right  and  left  sides. 

Modifications  in  the  Normal  Heart  Sounds. — Variations  in  character, 
intensity,  and  rhythm  are  to  be  considered.  There  are  marked  differences 
in  the  sounds  in  different  individuals  and  in  the  same  individual  at  differ- 
ent periods  of  life  and  under  varying  conditions  of  activity  and  emotion. 

Character. — The  heart  in  children  is  less  covered  by  the  lungs  than  in 
later  life  and  the  chest  wall  is  far  thinner  and  more  elastic.  It  follows 
that  the  sounds  though  feeble  are  more  distinctly  heard.  As  the  muscle 
is  smaller  and  thinner  the  valvular  element  of  the  first  sound  is  more  in 
evidence,  and  as  the  frequency  is  greater  the  long  pause  is  shortened  so 
that  the  rhythm,  which  at  birth  has  the  characteristic  tic-tac  of  the  fetal 
heart,  like  the  ticking  of  a  watch,  only  gradually  changes  to  that  above 
described  as  occurring  in  later  life. 

Embryocardia  is  a  common  condition  in  which  the  rhythm  suggests 
that  of  the  fetal  heart,  the  long  pause  being  shortened  and  the  first  and 
second  sound  presenting  nearly  the  same  acoustic  properties.  This  modifi- 
cation of  the  cardiac  rhythm  occurs  in  tachycardia,  the  cardiac  asthenia 
of  the  later   periods  of  exhausting   diseases   and   in   extreme   dilatation. 

The  first  sound  at  the  apex  is  not  only  somewhat  louder  in  powerful 
persons  with  well-developed  muscles  but  it  is  also  more  prolonged  than  in 
feeble  persons  who  lead  sedentary  lives — a  difference  due  to  an  increase 
of  the  muscular  factor  entering  into  the  production  of  the  sound. 

A  similar  increase  in  the  duration  and  intensity  of  the  first  sound 
occurs  under  conditions  of  bodily  exercise  and  mental  excitement.  Under 
these  circumstances  the  sound  is  occasionally  attended  by  curious  metallic 
reverberations,  the  cliquetis  metallique  of  the  French. 

Intensity. — In  young  persons  with  thin,  elastic  chest  walls  the  sounds 
of  the  heart  are  louder  and  more  distinct  than  in  older  persons,  in  whom  the 
walls  are  thicker  and  the  costal  cartilages  more  rigid.  Thick  layers  of  sub- 
cutaneous fat  may  render  the  sounds  faint  and  distant.  The  interposition 
of  the  thick  edge  of  a  voluminous  lung  may  have  the  same  effect.  There 
are  marked  differences  in  the  intensity  of  the  sounds  in  repose  and  activity. 

The  First  Sound  at  the  Apex. — The  first  sound  is  louder  and  more 
distinct  in  the  mitral  area  than  in  the  tricuspid,  but  in  young  persons 
under  conditions  of  excitement  or  after  great  muscular  effort  it  may  be 
heard  with  equal  clearness  and  intensity  over  the  whole  front  of  the  chest. 

The  Second  Sound  at  the  Base. — The  peculiarity  of  the  second 
sound  is  its  valvular  quality.  Its  intensity  varies  in  health  with  the  energy 
of  the  heart's  action.  It  has  been  assumed  that  the  intensity  of  the  aortic 
sound  under  normal  conditions  is  greater  than  that  of  the  pulmonary 
second  sound.     Vierordt,  however,  in  1885  first  called  attention  to  the  fact 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  179 

that  the  relative  intensity  of  these  two  components  of  the  second  sound 
varies  at  different  periods  of  life,  an  observation  that  has  been  confirmed 
by  other  recent  clinicians  and  especially  by  the  investigations  of  Creigh- 
ton  in  1899.  This  observer  found  that  in  90  per  cent,  of  healthy  children 
under  ten  years  of  age  the  pulmonic  second  sound  is  more  intense  than  the 
aortic;  in  66  per  cent,  between  the  tenth  and  twentieth  years  the  pul- 
monic sound  is  more  distinct ;  in  about  half  in  the  following  decade,  and 
after  the  thirtieth  year  the  proportion  gradually  declines  until  after  sixty, 
when  the  aortic  second  sound  is  more  intense — accentuated — in  almost 
every  case.  It  thus  appears  that  the  relative  intensity  of  the  two  elements 
of  the  second  sound  depends  upon  the  age  of  the  individual,  the  sound  in 
the  pulmonary  area  being  more  intense  in  early,  and  that  in  the  aortic 
area  more  intense  in  later  life,  while  in  middle  life  their  intensity  is  much 
the  same.  Cabot  suggests  that  "it  is  therefore  far  from  true  to  suppose 
that  we  can  obtain  evidence  of  a  pathological  increase  in  the  intensity  of 
either  of  the  sounds  at  the  base  of  the  heart  simply  by  comparing  it  with 
the  other.''  The  difficulty  lies  in  the  failure  on  the  part  of  the  auscultator 
to  recognize  the  difference  between  mere  loudness  or  intensity  which  may 
be  normal,  and  accentuation,  which  is  a  morbid  physical  sign. 

In  elderly  persons  the  second  sounds  are  frequently  heard  more 
distinctly  in  the  third  or  fourth  interspace  than  in  the  second. 

Rhythm. — The  derangements  of  rhythm  which  may  occur  in  health  are: 

1.  Gallop  Rhythm  in  which  the  Diastolic  Pause  is  Shortened  with  the 
Addition  of  an  Extra  Sound  of  the  Heart. — The  rhythm  suggests  the 
cadence  of  the  footfall  of  a  cantering  horse.  It  is  expressed  by  the 
repetition  of  the  syllables  "rat-ta-ta."  The  mechanism  of  its  produc- 
i  ion  is   not    clear. 

G.  Canby  Robinson  has  summarized  the  results  of  recent  studies  of 
gallop  rhythm  as  follows:  "Gallop  rhythm  of  the  heart  is  a  fairly  frequent 
clinical  phenomenon,  and  consists  in  the  presence  of  a  group  of  three 
cardiac  tones,  none  of  which  are  murmurs.  It  occurs  under  variable 
clinical  conditions.  That  form  of  gallop  rhythm  which  is  best  heard  at 
the  apex  or  over  the  central  part  of  the  precordium  may  be  divided 
into  the  presystolic,  protodiastolic,  and  mesodiastolic  types,  depending 
on  whether  the  extra  tone  falls  at  the  end,  at  the  beginning,  or  in  the 
middle  of  diastole.  Each  form  is  associated  with  a  characteristic 
cardiogram.  There  are  a  number  of  factors  which  probably  combine 
in   various  way-  to   produce  the  various  forms  of  gallop  rhythm. 

"Presystolic  gallop  rhythm  is  heard  in  two  classes  of  cases.  It  is 
heard  in   strongly  acting  hearts  in   which   a    muscle  sound    produced   by  a 

strongly  acting,  hypertrophied  auricle  is  probably  the  cause  of  the  extra 

tone;  and  it  is  also  heard  in  weak,  rapidly  acting  hearts  at  the  height  of 
acute  febrile  diseases,  at  which  time  there  is  possibly  a  delay  in  the  con- 
duction of  the  heart-heat    from  the  auricles  to  the  vent  ride-.      Under  these 

circumstances  the  sound  produced  during  the  contraction  of  the  auricles 
becomes  distinguishable  from  that  produced  during  the  contraction  of  the 

ventricles.  In  both  classes  of  cases,  the  extra  tone  seems  to  be  produced 
in  t  he  auricle  rather  than  in  the  ventricle.  Protodiastolic  and  mesodiastolic 
gallop  rhythm  are  caused  by  the  production  of  an  extra  tone  in  the  ven- 


180  MEDICAL  DIAGNOSIS. 

tricles.  The  factors  that  probably  combine  to  produce  this  extra  tone  are 
an  increase  in  the  amount  and  velocity  of  the  flow  of  blood  from  the  auricles 
into  the  empty  ventricles  and  a  loss  of  tone  of  the  heart  muscle  of  the 
ventricles.  The  longer  silent  period  in  cases  of  gallop  rhythm  does  not 
as  a  rule  occur  during  diastole,  but  is  usually  a  systolic  silence."    • 

This  derangement  of  the  cardiac  rhythm  may  sometimes  be  observed 
in  the  normal  heart  when  rapidly  acting  under  conditions  of  great  exertion 
or  excitement. 

2.  Reduplication  of  the  Second  Sound  at  the  Base  of  the  Heart. — Splitting 
of  the  second  sound  may  be  heard  at  the  base  of  the  heart  at  the  end  of 
full  inspiration,  especially  if  the  breath  be  held  or  after  active  muscular 
exertion.  Its  mechanism  probably  consists  in  the  asynchronous  closure 
of  the  aortic  and  pulmonary  valve  systems  as  the  result  of  heightened 
pressure  in  the  pulmonary  circuit. 

3.  Reduplication  of  the  First  Sound  at  the  Apex. — An  impure  first 
sound  may  occasionally  be  heard  at  the  apex,  especially  at  the  end  of 
expiration  under  normal  circumstances.  This  modification  varies  from  a 
mere  blur  or  prolongation  of  the  sound  to  a  distinct  repetition,  consti- 
tuting a  form  of  the  gallop  rhythm.  It  may  be  represented  by  the  syllables 
"trupp"  or  "turrupp."  In  health  it  is  not  constant  in  the  same  indi- 
vidual. It  has  been  attributed  to  conditions  temporarily  giving  rise  to  an 
increase  in  the  vis-a-fronte  of  one  or  the  other  ventricle. 

MODIFICATIONS  OF  THE  HEART  SOUNDS  IN  DISEASE. 

Variations  in  the  character,  intensity,  and  rhythm  which  transcend 
the  borders  of  health,  together  with  wholly  abnormal  or  adventitious 
sounds,  are  to  be  considered. 

Character. — The  acoustic  properties  of  the  heart  sounds  are  modi- 
fied not  only  by  changes  in  the  heart  itself  and  in  the  arteries  but  also  by 
pathological  conditions  in  the  adjacent  parts  and  the  state  of  the  chest 
walls  as  regards  elasticity  and  thickness.  Finally  the  character  of  the  heart 
sounds  is  modified  by  constitutional  conditions.  Changes  in  character  are 
commonly  associated  with  changes  in  intensity,  but  it  is  well  for  the 
student  to  train  himself  to  appreciate  modifications  of  character  and  of 
intensity  as  constituting  distinct  groups  of  physical  signs. 

1.  The  Heart. — The  first  sound  is  prolonged  and  dull  in  hypertrophy; 
when  the  associated  dilatation  is  marked  it  is  sometimes  very  clear  and 
sharp.  A  metallic  clinking — tintement  metallique — is  occasionally  heard 
to  the  right  of  the  apex-beat.  The  second  sound  is  loud  and  distinct,  often 
ringing  in  character  and  doubled.  When  valvular  lesions  are  present  the 
sounds  are  greatly  modified  and  replaced  or  accompanied  by  murmurs. 

In  hypertrophy  of  the  right  ventricle  the  first  sound  at  the  lower  part 
of  the  sternum  is  louder  and  fuller  than  normal;  but  with  much  associated 
dilatation  it  is  clearer  and  sharper.  Accentuation  of  the  pulmonary 
second  sound  is  frequently  present. 

In  dilatation  the  first  sound  is  shorter  and  sharper,  in  other  words, 
more  valvular  in  character  than  normal.  The  muscular  element  is  dimin- 
ished.    With  progressive  thinning  of  the  walls  these  changes  become  more 


PHYSICAL   DIAGNOSIS:    AUSCULTATION.  181 

marked.  The  second  sound  when  heard  in  aortic  insufficiency  may  be 
distinct,  or  faint  and  obscure;  when  there  is  dilatation  of  the  aortic  arch  it 
may  be  ringing  and  prolonged. 

The  second  sound  is  rarely  heard  in  the  aortic  area  in  aortic  stenosis  for 
the  reason  that  the  deformity  of  the  cusps  is  such  as  to  prevent  their  free  play. 

Accentuation  of  the  pulmonary  second  sound  is  an  important  sign  in 
mitral  insufficiency. 

The  first  sound  is  unusually  sharp  and  clear  in  mitral  stenosis,  while 
the  second  sound  in  the  second  left  interspace  is  strongly  accentuated  and 
sometimes  reduplicated. 

2.  The  Arteries.  —  Accentuation  of  the  aortic  second  sound  occurs 
in  arteriosclerosis.  —  especially  that  form  which  accompanies  chronic 
nephritis, — in  atheroma  and  dilatation  of  the  aortic  arch,  and  in  aortic 
aneurism.  It  is  the  sign  of  increased  arterial  tension  and  is  associated 
with  hypertrophy  of  the  left  ventricle. 

3.  Diseases  of  Neighboring  Organs. — In  pericardial  effusion  the  heart 
sounds  are  not  only  indistinct  but  they  also  have  a  peculiar  muffled  and 
distant  quality,  due  to  diffusion.  Accentuation  of  the  pulmonary  second 
sound  is  frequently  an  early  and  persistent  sign. 

In  some  cases  of  pneumothorax  the  heart  sounds  acquire  a  metallic 
quality;    in  pneumopericardium  they  are  feeble,  distant,  and  muffled. 

They  are  distant  and  muffled  in  pulmonary  emphysema,  well  trans- 
mitted in  consolidation  of  the  lung  and  in  chronic  interstitial  pneumonia 
and  pulmonary  phthisis,  and  sharp  and  ringing  during  cardiac  overaction. 
especially  in  young  persons  and  in  the  periods  of  excitement  and  palpita- 
tion which  occur  in  exophthalmic  goitre,  chlorosis,  and  anaemic  states. 

4.  Different  Conditions  of  the  Walls  of  the  Chest. — As  in  health  so  in 
disease,  remarkable  differences  in  the  heart  sounds  occur  as  the  result 
of  differences  in  the  chest  wall.  Through  the  thin  and  elastic  tissues  of 
the  young  the  sounds  are  conducted  with  great  distinctness;  they  are 
faint  and  diffuse  when  the  chest  walls  are  thick  and  fat,  and  when  the  car- 
tilages arc  calcified,  the  sternum  thickened,  or  when  deformities  of  the  chest 
derange  the  normal  relation  of  the  heart  to  the  wall,  or  finally  when  a  new 
growth  is  interposed. 

5.  Constitutional  Conditions.  —  The  first  sound  is  shortened  as  well 
as  faint  in  conditions  of  general  asthenia  such  as  result  from  actual  star- 
vation and  wasting  diseases.  In  enteric  fever  the  first  sound  becomes 
progressively  shorter,  more  indistinct  and  valvular  in  quality — a  change 
due  to  the  progressive  wasting  of  the  myocardium. 

Intensity.  The  significance  of  increase  or  decrease  in  the  intensity 
of  the  heart  sounds  as  morbid  physical  signs  has  already  to  some  extent 
been  indicated.  It  is  important  to  note  that  as  a  rule  increase  in  the 
intensity  of  the  first  sound  is  associated  with  its  prolongation,  while  de- 
crease in  intensity  is  attended  with  decrease  in  duration.  The  loud  first 
sound  is  in  strong  contrast  with  the  short  second  sound;  the  faint  first 
sound  resembles  it.  As  the  feeble  heart  is  commonly  also  a  rapid  heart. 
in  which  the  long  pause  is  shortened,  it  may  become  difficult  to  tell  which 
is  the  first  and  which  the  second  sound.  The  first  sound  corresponds  to 
the  impulse  at    the  apex  or  to  the  carotid  pulse. 


182  MEDICAL  DIAGNOSIS. 

Accentuation.  —  It  is  important  at  this  point  to  emphasize  the  dis- 
tinction between  "loudness"  and  "accentuation" — a  matter  not  always 
made  clear  in  the  books.  Loudness  or  sound  intensity  has  to  do  with  the 
volume  of  a  given  sound;  accentuation  is  that  acoustic  property  which 
indicates  suddenness  in  -"he  application  of  the  3nergy  by  which  the  sound 
is  produced.  The  first  sound  of  the  heart  is  often  loud,  even  booming, 
but  never,  according  to  my  belief,  accentuated.  It  may  have  a  slapping 
quality  as  in  mitral  stenosis,  but  that  is  something  altogether  different 
from  accentuation.  The  second  sound  of  the  heart  at  the  base  may  be  loud 
and  distinct  without  being  accentuated.  It  may  become  accentuated  with- 
out becoming  louder.  Accentuation  is  then  something  quite  different  from 
loudness.  The  word  conveys  the  idea  of  suddenness,  sharpness,  a  certain 
vibrating  quality  due  to  quick  and  sharp  tension.  Loudness  is  a  matter 
of  degree;  accentuation  a  matter  of  quality.  From  this  point  of  view 
accentuation  becomes  a  physical  sign  of  great  importance. 

The  first  sound  is  increased  in  intensity  in  conditions  which  cause 
the  heart  to  act  with  unusual  energy.  In  intense  emotional  states  the  first 
sound  is  greatly  increased  and  may  sometimes  be  heard  all  over  the  chest. 
Such  overaction  may  be  pathological,  as  in  mania  and  acute  febrile  states. 
The  first  sound  is  louder  than  normal  in  hypertrophy  of  the  left  ventricle, 
but  less  constantly  so  than  has  been  assumed;  even  with  a  considerable 
degree  of  associated  dilatation  the  sound  may  still  be  quite  intense. 

The  first  sound  is  enfeebled  in  conditions  of  general  asthenia  such  as 
result  from  starvation,  long-continued  fevers,  wasting  diseases,  hemorrhage, 
shock,  and  profound  exhaustion  from  over-exertion;  in  dilatation  of  the 
ventricles,  myocarditis,  fatty  heart,  and  rupture  of  the  compensation  in 
chronic  valvular  disease;  in  chlorosis  and  ansemia  and  in  all  conditions 
that  interfere  with  its  transmission  to  the  ear  of  the  auscultator,  such  as  fat 
in  the  chest  walls,  emphysema,  pleural  and  pericardial  effusions,  and  certain 
mediastinal  tumors.  In  conditions  in  which  direct  pressure  is  exerted  upon 
the  wall  of  the  heart  by  effusion  or  tumor,  its  action  is  impeded  and  its 
sound  enfeebled. 

The  second  sound  is  increased  in  intensity  in  nervous  overaction  of 
the  heart  and  in  all  conditions  in  which  the  lungs  are  retracted  so  as  to 
bring  the  aortic  arch  and  the  conus  arteriosus  into  more  extended  relation 
with  the  wall  of  the  thorax.  An  apparent  increase  in  the  loudness  of  one 
or  the  other  elements  of  the  second  sound  is  produced  by  the  retraction  of 
the  anterior  border  of  the  lung  upon  the  corresponding  side.  The  second 
sound  is  diminished  in  intensity  by  those  conditions,  both  general  and 
cardiac,  which  weaken  the  action  of  the  heart  and  diminish  the  intensity 
of  the  first  sound. 

The  significance  of  changes  in  the  intensity  of  the  aortic  and  pul- 
monary elements  in  the  second  sound  demands  consideration. 

It  has  already  been  pointed  out  that  in  normal  individuals  after  middle 
life  the  aortic  second  sound  is  more  intense  than  the  pulmonary.  A  mere 
increase  in  the  volume  of  the  sound  may  be  the  result  of  increased  cardiac 
action.  An  increase  associated  with  that  change  of  quality  designated  by 
the  term  accentuation  constitutes  a  morbid  physical  sign  and  becomes 
more  significant  in  proportion  as  the  accentuation  becomes  more  marked. 


PHYSICAL  DIAGNOSIS:    AUSCULTATION.  183 

Accentuation  of  the  aortic  second  sound  occurs  in  all  conditions  in 
which  the  arterial  blood-pressure — vis-a-f route  —  is  increased,  namely, 
arteriosclerosis,  chronic  nephritis,  and  in  aortic  aneurism  and  dilatation 
of  the  aortic  arch.  In  conditions  characterized  by  habitual  increase  in 
arterial  tension  there  is  usually  cardiac  hypertrophy. 

Diminution  in  the  intensity  of  the  aortic  second  sound  occurs  in 
conditions  in  which  the  blood  thrown  into  the  aorta  by  the  ventricular 
systole  is  reduced  in  amount  as  in  aortic  and  mitral  stenosis  and  to  some 
degree  also  in  mitral  insufficiency.  Under  these  circumstances  the  aortic 
second  sound  may  be  so  diminished  as  to  be  no  longer  heard  at  the  apex. 
"Weakening of  the  wall  of  the  heart,  as  in  fibrous  and  interstitial  myocarditis, 
fatty  degeneration,  and  extreme  dilatation,  likewise  gives  rise  to  enfeeble- 
ment  of  the  aortic  second  sound.  Relaxation  of  the  peripheral  arteries 
produces  the  same  effect.  The  aortic  second  sound  is  extremely  faint  in 
collapse  from  any  cause. 

The  pulmonic  second  sound  is  louder  than  the  aortic  in  children  and  in 
young  adults.  A  pathological  increase  in  the  loudness  of  this  sound  has  the 
same  significance  in  regard  to  the  pulmonary  circulation  that  an  increase 
in  the  aortic  second  sound  has  in  regard  to  the  general  circulation,  namely, 
an  augmentation  in  the  resistance  to  the  flow  of  the  blood.  This  occurs 
in  chronic  valvular  disease  of  the  heart,  especially  in  mitral  stenosis  and 
insufficiency,  and  in  various  pulmonary  diseases,  particularly  emphysema, 
chronic  bronchitis,  phthisis,  interstitial  pneumonia,  and  compression 
atelectasis.  These  conditions  are  associated  with  hypertrophy  of  the 
right  ventricle,  compensatory  in  nature;  when  the  compensation  fails, 
the  pulmonary  second  sound  becomes  faint  and  indistinct.  Under  all 
these  conditions  the  more  intense  pulmonary  second  sound  is  also 
accentuated. 

Weakening  of  the  pulmonary  second  sound  is  the  sign  of  a  weakened 
right  ventricle  or  tricuspid  insufficiency.  This  sign  is  of  great  value  in 
pneumonia  as  indicating  failure  of  the  right  ventricle.  The  pulmonic  second 
sound  should  therefore  be  systematically  studied,  since  it  affords  at  once 
indications  for  treatment  and  data  for  prognosis. 

Rhythm. — Allorrhythmia  is  the  general  term  used  to  designate  devi- 
ations from  the  normal  rhythm  of  the  heart.  See  Arrhythmia,  p.  468  et  seq. 
under  Radial  Pulse. 

Theories  of  the  Mechanism  of  the  Heart. — The  neurogenic  or  older 
theory  was  based  upon  the  assumption  that  the  rhythmic  contractions  of 
the  heart  muscle  are  due  to  stimuli  originating  in  the  nervous  system,  either 
in  the  motor  cells  of  the  brain  or,  as  modified  by  Yolkman,  in  the  cardiac 
ganglia.  The  myogenic  theory,  which  we  owe  to  the  brilliant  work  of 
Gaskell  and  Englemann,  is  of  recent  origin  and  ascribes  the  contractions 
to  automatic  impulses  originating  in  and  conducted  by  the  muscle.  The 
subsequent  studies  of  His,  Keith,  Tawara,  Erlanger  and  others  have 
shown  that  these  properties  are  possessed  not  by  the  myocardium  as  a 
whole  but  by  certain  highly  specialized  muscle  fibres  embryonic  in  type, 
which  differ  in  structure  from  the  muscle  fibres  of  the  adult  heart  and  arc 
present  in  the  remains  of  the  primitive  cardiac  tube.  These  muscle  fibres 
constitute  a  system  beginning  at  the  junction  of  the  superior  vena  cava 


184  MEDICAL  DIAGNOSIS. 

and  the  auricle  as  a  small  net-like  mass  recently  described  by  Keith  and 
Flask  and  now  regarded  as  the  seat  of  the  primary  impulses,  continued  in 
the  right  auricle  as  the  atrio-ventricular  orTawara's  node  and  passing  thence 
into  the  septum  and  branching  into  both  ventricles  as  the  bundle  of  His. 
The  myogenic  theory  during  the  short  period  since  it  was  first  formulated 
has  aroused  widespread  interest  among  anatomists,  physiologists  and 
clinicians  and  been  singularly  productive  in  its  influence  upon  biological 
investigation  and  practical  medicine.  Among  other  matters  it  has  brought 
about  an  orderly  classification  of  the  cardiac  arrhythmias  and  shed  mUv/h 
light  upon  their  significance. 

Properties  of  the  Heart  Muscle. — The  studies  of  Gaskell  and  Engle- 
mann  have  shown  the  following  properties  to  be  inherent  in  the  myocardium 
and  to  constitute  the  basis  of  the  physiology  and  clinical  pathology  of  the 
heart:  1.  Stimulus  production — the  capability  of  the  heart  to  generate 
automatic  rhythmic  impulses.  2.  Excitability — the  ability  to  respond  to 
an  adequate  stimulus  by  contraction.  3.  Conductivity — the  power  of  trans- 
mitting the  impulse  from  one  place  in  the  heart  to  another.  4.  Con- 
tractility— the  capacity  to  react  to  more  favorable  conditions,  in  respect 
of  rest,  nutrition,  temperature  and  so  on,  with  stronger  contractions. 
5.  Tonicity — the  degree  of  contraction  which  the  heart  maintains  during 
diastole,  by  virtue  of  which  the  total  volume  of  the  organ  and  the  size  of 
the  cavities  are  less  than  if  full  muscular  relaxation  were  to  occur  in 
diastole. 

Two  other  properties  of  the  myocardium  are  essential  to  the  myogenic 
theory.  The  first  is  known  as  the  All  or  None  Law.  It  is  the  formulation 
of  the  fact  that  while  a  skeletal  muscle  reacts  in  proportion  to  the  vigor 
of  the  stimulus,  the  heart  has  only  one  kind  of  response  to  all  degrees  of 
stimulation.  A  stimulus  barely  strong  enough  to  cause  a  contraction  will 
cause  the  most  powerful  contractions  of  which  the  heart  is  capable  under 
given  conditions  at  the  moment.  No  increase  of  stimulation  will  increase 
the  force  of  the  contraction. 

The  second  is  the  Absence  of  Tetanus.  A  skeletal  muscle  reacts  to 
continuous  rapid  stimulation  by  continuous  contraction,  whereas  the 
vertebrate  heart  responds  with  a  single  contraction  and  to  continuous 
stimulation  by  a  series  of  distinctly  separate  contractions.  This  is  attrib- 
uted to  the  refractory  period,  the  reaction  to  the  stimulus  failing  to  occur 
until  the  effect  of  the  previous  contraction  has  ceased. 

The  influence  of  the  vagus  and  the  accelerators  upon  the  action  of  the 
heart  is  important  in  connection  with  the  myogenic  theory.  The  rate  of 
beats,  the  conductivity,  the  excitability  and  contractility  are  decreased 
by  the  influence  of  the  vagus  fibres  and  increased  by  that  of  the  accelerator 
fibres.  Englemann  holds  that  there  are  separate  nerve  fibres  which  influence 
each  of  those  functions  and  designates  those  which  regulate  the  rate  chrono- 
tropic; those  which  influence  the  conductivity  dromotropic;  those  which 
modify  the  irritability  bathmotropic  and  those  which  act  upon  the  con- 
tractility inotropic.  Finally,  the  influence  of  the  elasticity  and  contractility 
of  the  blood-vessels  upon  the  heart  through  the  action  of  the  vasomotor  sys- 
tem enters  largely  into  pathological  considerations  and  has  an  important 
bearing  upon  diagnosis. 


PHYSICAL  DIAGNOSIS:  AUSCULTATION. 


185 


Methods. — Formerly  the  arterial  pulse  and  apex  beat  were  the  guides 
to  the  study  of  the  cardiac  rhythm.  The  sphymograph  and  cardiograph 
added  something  to  our  knowledge  but  less  than  was  hoped.  Auscultation 
revealed  the  sounds  and 
murmurs  which  attended 
the  beginning  and  the  end 
of  the  ventricular  systole 
and  recognizes  ventricular 
contractions  which  fail  to 
reach  the  superficial  arte- 
ries as  pulse  beats.  The 
defect  of  all  of  these  meth- 
ods is  that  they  give  no 
positive  sign  of  the  condi- 
tion of  the  auricles.  Trac- 
ings of  the  jugular  pulse 
reveal  the  condition  of  the 
right  auricle.  The  poly- 
graph tells  the  whole  story 
of  the  contractions  of 
the  auricles  and  ventricles, 
while  the  sphygmogram  and  cardiogram  supply  definite  data  in  regard 
to  the  opening  of  the  aortic  valve  system.  That  this  story  has  been  fully 
and  finally  interpreted  cannot  be  said. 

ABNORMAL  OR  ADVENTITIOUS  SOUNDS. 

Upon  auscultation  over  the  heart  and  great  vessels  sounds  are  heard  in 
pathological  conditions  which  differ  from  the  normal  heart  sounds.  These 
sounds  bear  a  definite  relation  to  the  cardiac  cycle  and  are  dependent  upon 
the  action  of  the  heart.  Those  which  have  their  origin  within  the  heart  are 
spoken  of  as  endocardial,  those  which  arise  outside  of  the  heart  as  exocardial. 

A.  Endocardial  adventitious  sounds  are  called  murmurs.     They  are: 
Organic;  Functional,  Accidental  or  Hsemic. 

B.  Exocardial  adventitious  sounds,  sometimes  called   pericardial   mur- 

murs, include: 


Fig.  81a. — Tracings  of  the  jugular  pulse  beat,  carotid  and 
radial  pulses.  The  perpendicular  lines  represent  the  time  of  the 
following  events:  1,  the  beginning  of  the  auricular  systole;  2, 
the  beginning  of  the  ventricular  systole  ;  3,  the  appearance  of  the 
pulse  in  the  carotid  ;  4,  the  appearance  of  the  pulse  in  the  radial  ; 
5,  the  closing  of  the  semilunar  valves  :  6,  the  opening  of  the  tri- 
cuspid valves.     (MacKenzie.) 


Pericardial  Friction; 
Pleuropericardial  Friction; 
Cardiopulmonary  Murmurs ; 


The  Precordial  Rales  of  Emphysema; 

Pericardial  Splashing; 

The  Murmurs  of  Aneurism. 
A.  Endocardial  Murmurs. — Much  confusion  has  arisen  from  attempts 
to  explain  auscultatory  phenomena  in  musical  terms.  Neither  the  sounds  of  the 
heart — sometimes  erroneously  called  'Hones" — nor  cardiac  murmurs,  with 
exceptions  presently  to  be  mentioned,  are  musical  phenomena.  They  both 
arise  from  irregular  sound-producing  vibrations  which  lack,  as  a  rule,  the 
rapidity  necessary  to  the  production  of  musical  tones.  A  "sound"  of  the 
heart  is  produced  by  a  single  sudden  derangement  of  the  equipoise  of  sound- 
producing  structures,  which  are  thrown  into  vibration;  a  murmur  by  the  con- 
tinuous action  of  forces  which  maintain  such  vibrations.    The  sound  presently 


186  MEDICAL  DIAGNOSIS. 

ceases;  the  murmur  continues  so  long  as  the  force  which  causes  the  vibra- 
tions continues  to  act.  The  sound  corresponds  in  a  way  to  a  single  blow 
upon  a  drum;  the  murmur  to  the  continuous,  rapidly  repeated,  but  less  in- 
tense sounds  known  as  the  roll  of  the  drum;  or  the  sound  to  the  picking  of  the 
violin  string,  the  murmur  to  the  continuous  note  made  by  the  drawing  of 
the  bow.  But  both  these  comparisons  have  the  fault  of  likening  musical 
phenomena  to  those  which  usually  lack  the  musical  quality.  Furthermore 
the  mechanism  by  which  sounds  and  murmurs  are  produced  is  different. 

The  Mechanism  of  Endocardial  Murmurs. — The  heart  sounds  arise  from 
the  contraction  of  the  heart  muscle,  the  vibration  of  the  blood  mass,  and 
the  sudden  tension  of  the  auriculoventricular  and  semilunar  valve  sys- 
tems. When  murmurs  arise  a  new  set  of  physical  conditions  comes  into 
play,  namely,  fluid  veins  (see  p.  160).  These  swirls,  or  currents  within 
currents  of  the  blood,  are  attended  with  vibrations,  which,  first  com- 
municated to  the  wall  of  the  heart  or  vessels  and  thence  by  way  of  the 
intervening  tissues  to  the  surface  of  the  chest,  are  recognized  by  the 
auscultator  as  auditory  phenomena — murmurs. 

The  Mechanism  of  Organic  Murmurs — Lesions. — In  by  far  the  greater 
number  of  instances  the  fluid  veins  are  due  to  actual  lesions  of  the  heart, 
and  for  this  reason  the  murmurs  are  known  as  organic.  The  lesions  mostly 
involve  the  valves,  a  fact  which  is  indicated  by  the  descriptive  adjective 
valvular.  They  are  on  the  one  hand  inflammatory  and  proliferative  or 
adhesive,  on  the  other  sclerotic.  Those  that  occur  in  early  life  are  usu- 
ally inflammatory;  those  which  develop  later  are  mostly  sclerotic;  but 
the  inflammatory  lesions  of  the  valves  undergo  sclerotic  changes,  and  old 
sclerotic  valves  are  frequently  the  seat  of  recurrent  inflammatory  proc- 
esses— recurrent  endocarditis.  As  the  result  of  each  of  these  processes 
involving  the  valves,  deformities  arise.  Inflammation  causes  vegetations, 
thickening,  adhesions,  and  in  extreme  cases  necrosis;  sclerosis  gives  rise 
to  thickening,  retraction,  crumpling;  both  result  in  loss  of  elasticity  and 
freedom  of  movement.  In  cases  of  long  standing  lime  salts  are  deposited 
and  the  rigidity  and  deformity  are  correspondingly  increased. 

Stenosis  and  Insufficiency. — The  impairment  of  function  is  two- 
fold. That  function  of  the  valves  by  which  they  yield  before  the  blood 
stream  and  permit  it  to  pass  unhindered  from  auricle  to  ventricle  or 
from  ventricle  to  artery  may  be  deranged.  The  condition  is  known  as 
stenosis  or  narrowing,  and  the  fluid  veins  are  developed  in  the  normal 
direction  of  the  blood  stream.  Or  that  function  by  virtue  of  which  the 
valves  close  their  respective  orifices  is  at  fault,  and  there  is  valvular 
insufficiency  or  incompetency,  the  fluid  veins  developing  in  the  reverse 
direction.  Very  often  both  these  functions  are  impaired,  and  the  condi- 
tion is  that  of  combined  stenosis  and  insufficiency,  with  double  murmurs. 

Relative  Insufficiency.  —  Again,  the  orifice  guarded  by  a  valve 
system  may  be  enlarged  in  consequence  of  the  dilatation  of  the  heart,  so 
that  the  edges  of  the  valves  may  be  unable  to  meet  and  close  it.  This  con- 
dition is  known  as  relative  insufficiency  or  incompetence,  and  is  dependent 
not  upon  lesions  of  the  valves,  but  upon  nutritive  or  degenerative  lesions 
of  the  heart  muscle.  Acute  relative  insufficiency  such  as  sometimes  accom- 
panies the  heart  failure  of  violent  exertion  is  due  to  relaxation  of  the  wall 
of  the  heart  and  papillary  muscles. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  187 

Roughening  of  the  surfaces  of  the  valves  or  of  the  parts  immediately 
adjacent  to  them  and  sudden  dilatation  of  the  artery  just  beyond  the  valve 
system  may  lead  to  the  production  of  a  murmur. 

The  deformity  which  gives  rise  to  an  endocardial  murmur  may  be  of  all 
degrees,  from  such  as  only  slightly  impair  the  function  of  the  valve  system 
to  a  stenosis  which  leaves  a  tiny  orifice  or  mere  chink  for  the  passage  of 
the  blood  or  an  incompetence  that  is  almost  complete  and  transfers  the 
pressure  of  the  blood  column  to  the  wTall  of  the  chamber  of  the  heart  which 
is  immediately  behind  the  defective  valve,  namely,  the  left  ventricle  in 
aortic  insufficiency  and  the  left  auricle  in  mitral  insufficiency.  A  projecting 
firm  vegetation  or  rigid  spicule  or  the  inelastic  edge  of  a  sclerotic  valve 
may  be  the  cause  of  a  systolic  murmur,  where  there  is  practically  no 
actual  narrowing  of  the  orifice.  One  of  the  first  lessons  for  the  student 
of  heart  murmurs  to  learn  is  that  by  no  means  every  systolic  murmur 
having  its  point  of  maximum  intensity  in  the  aortic  area  is  the  sign  of 
aortic  stenosis. 

Stenosis  or  Narrowing  of  an  Orifice  Guarded  by  a  Valve 
System. — There  is  impairment  of  the  function  by  which  the  valves  open 
at  the  physiological  moment.  The  flow  of  the  blood  is  obstructed  and 
under  ordinary  circumstances  a  murmur  is  produced,  which  is  spoken  of 
as  an  obstructive  murmur.  If  the  heart  be  very  feeble,  marked  obstruc- 
tion may  exist  without  producing  a  murmur  that  can  be  recognized.  If  the 
left  auriculoventricular  orifice  is  involved,  the  condition  is  known  as  mitral 
stenosis  or  obstruction;    if  the  aortic,  as  aortic  stenosis  or  obstruction. 

Incompetence  or  Insufficiency. — The  function  of  the  valves  by 
which  they  close  the  orifice  is  impaired  and  a  portion  of  the  blood  which 
has  just  passed  through  the  orifice  escapes  from  the  main  stream  and  flows 
back  into  the  chamber  of  the  heart  whence  it  came.  This  pathological 
event  is  known  as  regurgitation,  and  the  murmur  which  attends  it  is  called 
a  regurgitant  murmur.  We  then  have  mitral  and  aortic  incompetence, 
insufficiency  or  regurgitation  as  one  or  the  other  of  these  valve  systems  is 
affected. 

Valvular  lesions  of  the  right  side  of  the  heart  are  of  infrequent  occur- 
rence. They  are  sometimes  the  result  of  developmental  defects  or  prenatal 
endocarditis.  However  produced  they  cause  similar  impairment  of  the 
valve  functions,  manifest  by  murmurs — tricuspid  and  pulmo.iary  stenosis 
and  incompetence.  Stenosis  is  always  due  to  deformity  of  the  segments 
of  a  valve  system.  Incompetence  is  mostly  due  to  the  same  cause,  but 
not  always.  The  deformity  which  prevents  a  valve  from  fully  opening 
also  generally  prevents  it  from  fully  closing. 

Combined  stenosis  and  incompetence  arises  under  the  conditions 
just  indicated.  The  lesion  is  a  "double"  one  and  manifests  itself  by  a 
"double"  or  "to-and-fro  "  murmur. 

Incompetence  may,  however,  arise  in  the  absence  of  stenosis  as  the 
result  of  (a)  a  lesion  by  which  a  valve  segment  has  been  destroyed  by 
ulcerative  endocarditis  or  has  contracted  adhesions  to  the  wall  of  the 
heart,  or  (b)  of  relaxation  of  the  cardiac  muscle,  as  in  relative  insufficiency. 

Stenosis  without  incompetence  is  comparatively  infrequent;  incom- 
petence without  stenosis  is  not  very  uncommon. 


188  MEDICAL  DIAGNOSIS. 

Valvular  lesions  exert  their  effect  (a)  upon  the  blood  stream  within 
the  heart,  (b)  upon  the  walls  of  the  heart,  (c)  upon  the  viscera,  and  finally 
(d)  upon  the  peripheral  circulation. 

(a)  The  Effect  of  the  Valvular  Lesions  which  Produce  Endo- 
cardial Murmurs  upon  the  Blood  Stream  within  the  Heart. — The 
beginning  of  evil  in  stenosis  and  incompetence  is  the  same.  It  consists 
in  a  reduction  of  the  quantity  of  blood  which  eventually  passes  the 
diseased  valve  system  with  each  revolution  of  the  heart.  In  stenosis  a 
portion  of  the  stream  corresponding  to  the  extent  of  the  pathological 
barrier  is  held  back;  in  incompetence  a  portion  corresponding  to  the 
degree  of  the  pathological  defect  returns  into  the  chamber  whence  it 
came — regurgitates.  The  result  is  a  tendency  to  retardation  of  the  flow, 
diminution  in  the  volume  of  blood  entering  the  arteries,  and  increase  in 
the  volume  retained  in  the  veins,  with  progressive  transference  of  blood- 
pressure  from  the  arterial  to  the  venous  side  of  the  circulation.  Were  this 
tendency  unchecked  every  case  of  valvular  disease  would  in  a  short  time 
terminate  in  death,  the  venous  pressure  rising  and  the  arterial  falling  until 
the  circulation  becomes  no  longer  possible.  This  result,  which  is  the  usual 
cause  of  death  in  valvular  disease,  is  postponed  for  an  indefinite  period  by 
compensatory  changes  in  the  muscle  of  the  heart  itself.  It  is  true  these 
changes  are  consecutive  to  the  lesion,  but  as  the  latter  is  progressive,  the 
former  are  correspondingly  progressive.  When  the  one  advances  at  the 
same  rate  as  the  other  a  physiological  balance  is  again  established,  the 
stability  of  which  depends  upon  the  tardiness  of  the  valvular  disease  on  the 
one  hand,  and  the  ability  of  the  hypertrophied  heart  muscle  to  maintain 
its  nutrition  on  the  other.  When  extensive  valvular  defects  develop  sud- 
denly or  are  rapidly  progressive,  compensation  is  not  established  and 
death  occurs  in  a  short  time. 

(b)  The  Effects  upon  the  Walls  of  the  Heart. — The  immediate 
effects  of  the  separation  of  the  blood  stream  into  a  major  part  circulating 
under  physiological  conditions  and  a  minor  part  held  back  under  patho- 
logical influences  are  exerted  upon  the  walls  of  the  chamber  behind  the 
affected  valve  system.  They  are  first  dilatation,  then  hypertrophy.  These 
changes  may  affect  the  whole  organ,  the  heart  acting  as  a  single  muscle 
and  undergoing  a  general  enlargement  in  response  to  the  increased  work 
required  of  it;  more  commonly  they  affect  one  or  more  of  the  chambers 
and  in  particular  that  chamber  immediately  subjected  b}r  the  valvular 
lesion  to  increase  in  its  blood  contents  in  diastole  and  to  a  necessary 
increase  in  its  energy  in  systole  in  order  to  overcome  the  obstacle  in  stenosis 
or  propel  an  augmented  volume  of  blood  in  incompetence.  In  mitral 
stenosis  the  left  auricle  cannot  empty  itself  and  receives  blood  from  the 
pulmonary  circuit;  in  mitral  incompetence  it  receives  blood  at  the  same 
moment  from  the  pulmonary  circuit  and  the  left  ventricle;  in  combined 
mitral  lesions  some  blood  is  retained  and  some  regurgitates,  while  the 
physiological  supply  enters  by  the  pulmonary  veins.  Consequently  the 
left  auricle  is  first  dilated  and  then  hypertrophied.  In  aortic  stenosis  the 
left  ventricle  cannot  empty  itself  and  in  diastole  the  blood  received  from 
the  left  auricle  is  augmented  by  that  retained  at  the  time  of  the  previous 
systole;    in  aortic  incompetence  blood  enters  the  left  ventricle  in  diastole 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  189 

at  the  same  moment  from  two  sources,  the  left  auricle  and  the  aorta; 
in  combined  aortic  disease  the  blood  coming  from  the  left  auricle  is 
augmented  by  that  retained  at  the  previous  systole  and  that  returning 
from  the  aorta.  Under  these  circumstances  the  left  ventricle  is  first  dilated 
and  then  hypertrophied.  It  is  important  to  bear  in  mind  the  cardinal 
fact  that  all  these  changes,  like  the  lesion  itself,  are  slight  at  first  and 
gradually  progress,  and  that  in  the  early  stages  neither  the  dilatation 
nor  the  hypertrophy  can  be  recognized  by  the  ordinary  methods  of  physical 
diagnosis.  Even  at  this  period  the  murmurs  indicative  of  the  respective 
lesions  are  commonly  quite  audible,  often  loud  or  harsh,  and  months 
may  elapse  before  the  signs  of  enlargement  of  the  heart  or  venous  stasis 
can  be  determined.  The  diagnosis  rests  upon  the  presence  and  characters 
of  the  murmur.  Nevertheless  it  is  an  error  to  speak  of  this  stage  as  pre- 
ceding compensation.  There  are,  however,  cases  of  rapidly  developing 
lesions  in  which  complete  compensation  is  only  gradually  attained;  some 
in  which  it  is  never  reached.  If  the  quantity  of  blood  held  back  in  stenosis 
or  regurgitated  in  incompetence  be  represented  by  x,  it  is  evident  that 
there  must  be  an  increased  capacity  of  the  affected  chamber,  represented 
by  the  same  symbol,  and  that  the  chamber  must  be  dilated  to  that 
extent.  While  if  the  resulting  hypertrophy  of  the  wall  of  the  chamber  be 
such  as  to  enable  it  to  propel  the  normal  quantity  of  blood  plus  x,  it  is 
evident  that  a  condition  is  established  in  respect  to  the  volume  of  blood 
maintained  in  circulation,  which  is  practically  normal  despite  the  valvular 
lesion,  and  this  condition  is  known  as  compensation.  This  condition  exists, 
however,  by  virtue  of  an  abnormal  increase  in  the  nutrition  and  work  of 
the  heart  muscle  and  at  the  expense  of  the  normal  reserve  power  of  the 
heart,  and  is  therefore  unstable.  It  consists  in  a  degree  of  dilatation  and 
hypertrophy  combined  and  in  ratio  to  the  valvular  defect,  but  demands 
for  its  maintenance  a  hypertrophy  slightly  in  excess  of  the  dilatation.  The 
nutrition  of  the  overgrown  and  overworked  muscle  ultimately  fails  and 
dilatation  develops  in  excess  of  hypertrophy.  The  compensation  under 
these  circumstances  is  said  to  be  at  first  "deranged"  or  "failing,"  later 
"broken  "  or  "ruptured."  It  is  a  question  of  degree.  In  a  small  proportion 
of  the  cases  failure  of  compensation  occurs  in  the  absence  of  marked 
increase  in  the  size  of  the  affected  chamber  or  chambers  of  the  heart 
and  has  I  icon  ascribed  to  derangement  of  the  innervation  of  the  heart. 

(<■)  Kiii.<T>  ri'o.s  Tin:  Viscera. — Compensation,  while  adequate  to 
the  maintenance  of  a  fair  degree  of  health  for  an  indefinite  period,  is  never 
complete.  There  is  always  increased  resistance  to  the  onward  flow  of  the 
arterial  blood  and  a  corresponding  increase  in  the  blood-pressure  upon  the 
venous  Bide  Of  the  circulation.  This  results  in  increased  fulness  of  the 
pulmonary  circuit,  manifest  by  accentuation  of  the  pulmonary  second 
sound,  hypertrophy  of  the  right  ventricle  and  a  tendency  to  passive  hyper- 
emia of  the  viscera  in  general;  hence,  accentuation  of  the  aortic  second 
Bound,  dyspnoea  upon  exertion,  a  peculiar  liability  to  bronchial  catarrh 
and  t lie  occasional  occurrence  of  blood-streaked  sputum  or  slight  haemop- 
tysis phenomena  which  are  common  in  mitral  disease  even  while  the 
compensation  remains  fairly  godd.  [JpOD  failure  of  compensation  there  is 
marked    venous   engorgement   of  the   viscera,  with   grave  derangement    of 


190  MEDICAL  DIAGNOSIS. 

function,  shown  on  the  part  of  the  lungs  by  marked  dyspncea  or  orthop- 
nea, cyanosis,  cough,  and  the  occasional  expectoration  of  frothy  blood; 
of  the  liver  and  gastro-intestinal  organs  by  loss  of  appetite,  deficient  diges- 
tion, nausea,  slight  jaundice  and  constipation;  on  the  part  of  the  kidneys 
by  scanty  urine  and  albuminuria.  Dulness,  stupor,  somnolence  with  ina- 
bility to  sleep  are  symptoms  of  the  derangement  of  the  cerebral  circulation. 

(d)  Effects  upon  the  Peripheral  Circulation. — While  compen- 
sation is  maintained,  dropsy,  as  the  result  of  valvular  lesions,  does  not 
occur.  There  is  sometimes  to  be  found  slight  pretibial  oedema,  especially 
after  fatiguing  exertion  or  long  standing.  When  compensation  fails,  how- 
ever, the  diminished  arterial  pressure  and  the  increased  venous  pressure 
interfere  with  the  circulation  of  the  blood  in  the  capillary  zone  and  give 
rise  to  oedema.  Under  these  circumstances,  there  is  an  accumulation  of 
extravascular  serum  about  the  capillaries  and  a  retardation  of  the  lymph- 
flow.  Hence  the  visceral  derangements  are  not  only  hyperaemic,  they  are 
also  cedematous.  The  action  of  gravity  renders  this  accumulation  of  extra- 
vascular  fluid  early  manifest  in  the  dependent  parts,  namely,  the  legs  and 
feet.  As  it  increases,  the  thighs,  genitalia,  and  loins  become  involved,  and 
finally  there  is  general  oedema  with  effusion  into  the  serous  sacs.  The 
dropsy  of  heart  disease  is  often  irregularly  distributed,  but  its  presence 
in  particular  localities  may  usually  be  explained  by  the  relatively  loose 
arrangement  of  the  subcutaneous  or  other  tissues  involved,  postural 
influences,  and  the  action  of  gravity. 

Compensation  in  mitral  disease  commonly  fails  by  degrees,  with 
periods  of  improvement  following  rest  and  treatment,  and  the  ultimate 
catastrophe  usually  occurs  after  impaired  health  of  prolonged  duration. 

Compensation  in  aortic  disease  is  chiefly  maintained  by  the  left  ven- 
tricle, which  often  becomes  enormously  hypertrophied,  —  cor  bovinum. 
There  is  some  increase  in  the  venous  pressure,  since  the  ventricle  receives 
its  blood  in  diastole  not  only  from  the  auricle  but  also  from  the  aorta, 
but  so  long  as  the  mitral  valve  remains  competent,  the  visceral  engorge- 
ment and  general  oedema  which  characterize  the  dyscrasia  of  the  stadium 
ultimum  of  mitral  disease  do  not  occur.  Precordial  pain,  angina  pectoris, 
and  momentary  faintness  upon  rising  or  at  stool  are  common,  and  in  many 
cases  the  rupture  of  compensation  is  immediate  and  instantly  fatal,  death 
occurring  with  the  heart  in  asystole. 

The  Mechanism  of  Functional,  Accidental,  or  Hsemic  Murmurs.  —  The 
murmurs  designated  by  these  terms  are  not  signs  of  disease  of  the  valves 
or  orifices  of  the  heart.  The  frequency  of  their  occurrence  enables  us 
to  determine  with  precision  that  they  do  not  correspond  to  anatomical 
changes  in  the  organ  found  upon  examination  after  death.  The  mechanism 
by  which  they  are  produced  has  been  the  subject  of  much  controversy, 
but  none  of  the  explanations  advanced  has  been  generally  accepted. 
Functional  murmurs  are  almost  exclusively  systolic  and  are  heard  over  a 
limited  space  in  the  pulmonary  area.  They  have  been  ascribed  to  dila- 
tation of  the  conus  arteriosus,  to  the  fact  that  in  anaemia  and  similar 
conditions  there  is  lowered  tonicity  of  the  arterial  walls  which  undergo  an 
abnormal  dilatation  at  the  time  of  the  systole,  and  to  the  lowered  blood- 
pressure  of  anaemia  in  the  aorta  and  pulmonary  artery,  which,  in  connec- 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  191 

tion  with  the  relatively  high  intraventricular  pressure  at  the  beginning  of 
systole,  prevents  the  closure  of  the  semilunar  valves  and  the  systolic 
tension  of' the  vessels,  with  the  result  that  a  systolic  murmur  arises 
upon  the  passage  of  the  blood  into  the  large  vessels  at  the  moment  of 
physiological  stenosis — contraction  of  the  cardiac  sphincters. 

Diastolic  functional  murmurs,  which  are  so  rare  that  they  scarcely 
demand  consideration  for  diagnostic  purposes,  are  probably  venous  mur- 
murs transmitted  to  the  innominata  or  vena  cava  and  heard  at  the  base 
of  the  heart. 

The  Significance  of  Endocardial  Murmurs. — In  order  to  determine  the 
diagnostic  meaning  of  a  murmur  heard  upon  auscultation  of  the  precordial 
area,  we  must  first  answer  the  following  questions:  Is  it  endocardial 
or  exocarclial?  (See  page  185.)  If  endocardial  is  it  organic  or  functional? 
'  See  page  196.)  Having  found  it  to  be  an  endocardial  murmur  of  organic 
origin  we  must  then  ascertain  (1)  its  time  in  the  cardiac  cycle;  (2)  its 
point  of  maximum  intensity;  (3)  the  direction  in  which  it  is  propagated 
and  the  area  over  which  it  can  be  heard;  (4)  its  relation  to  the  normal 
sounds  of  the  heart;  (5)  its  acoustic  properties,  and  (6)  the  effects  of 
exercise,  respiration,  and  posture  upon  it. 

(1)  The  Time  of  Murmurs  in  the  Cardiac  Cycle. — The  determina- 
tion of  this  point  is  of  primary  importance.  For  diagnostic  purposes  the 
systole  may  be  regarded  as  lasting  from  the  beginning  of  the  first  sound  of 
the  heart  until  the  second  sound;  the  diastole  from  the  beginning  of  the 
second  sound  until  the  beginning  of  the  first  sound  in  the  next  revolution  of 
the  heart.  A  murmur  heard  at  the  time  of  the  first  sound  or  replacing  the 
first  sound  or  extending  into  or  developing  in  the  period  between  the  first 
and  the  second  sounds  is  systolic.  Murmurs  which  develop  in  the  latter 
period  are  designated  late  systolic. 

A  murmur  which  occurs  at  the  time  of  the  second  sound  or  replaces  it 
is  diastolic.  Murmurs  which  occur  during  the  last  portion  of  the  diastole 
and  run  up  to  the  first  sound  are  known  as  presystolic. 

When  the  heart  is  acting  moderately  there  is  no  difficulty  in  recognizing 
the  first  and  second  sounds  by  their  respective  characters,  and  the  long  and 
short  silences  by  their  relative  duration.  But  when  the  heart  is  rapid  the 
different  acoustic  characters  of  the  two  sounds  cannot  always  be  made  out 
and  the  rhythm  is  so  deranged  that  the  difference  between  the  long  and 
the  short  silence  is  less  marked.  Under  these  circumstances  the  systole 
may  be  determined  by  palpation  with  the  finger  over  the  apex  or  the 
cain iid  artery  during  auscultation,  or  by  inspection  if  the  double  stetho- 
Bcope  is  used.  The  interval  between  the  time  of  the  cardiac  impulse  and 
the  radial  pulse  renders  the  latter  a  misleading  guide  for  this  purpose. 

(2)  The  Point  of  Maximum  Intensity  of  Murmurs. — The  area  in 

which  a  murmur  is  best  heard  is  likewise  of  cardinal  importance  in  diag- 
nosis.     The   murmur  IS  loudest    at    the   poinl    of  its   production   and   is   best 

transmitted  in  the  direction  of  the  blood  stream  in  which  the  fluid  veins 

which  produce  it  are  developed.  It  is  in  accordance  with  these  laws  that  a 
murmur  having  its  poinl  of  greatest  intensity  in  the  mitral  area  has  its 
origin  at  the  mitral  valve.  It  is  necessary  in  this  connection  to  bear  in 
mind   the  fad   that    the  mitral  area  is  not   constant  in  the  normal  position 


192  MEDICAL  DIAGNOSIS. 

but  that  it  shifts  with  displacement  of  the  heart.  In  a  limited  proportion 
of  cases  of  mitral  disease  this  murmur  is  best  heard  to  the  right  of  the 
normal  position  of  the  impulse,  and  in  rare  instances  at  the  left  border  of 
the  sternum  higher  up,  even  as  high  as  the  punctum  maximum  of  the 
pulmonary  second  sound. 

It  is  also  in  accordance  with  the  above  laws  that  murmurs  heard  in 
the  pulmonary  area,  namely,  the  second  left  intercostal  space,  have  their 
origin  in  the  conus  arteriosus  or  at  the  pulmonary  orifice;  that  murmurs 
having  their  maximum  intensity  at  the  right  lower  border  of  the  sternum, 
at  the  level  of  the  fourth  and  fifth  intercostal  spaces,  or  at  the  base  of  the 
ensiform  cartilage  are  produced  at  the  tricuspid  orifice,  and  that  murmurs 
whose  maximum  intensity  is  in  or  near  the  aortic  area  have  their  origin 
at  the  aortic  orifice.  Murmurs  arising  at  this  point  very  often,  however, 
are  best  heard  over  the  upper  part  of  the  body  of  the  sternum  near  its 
left  border  or,  less  frequently,  at  the  apex  or  over  the  lower  part  of  the 
sternum — aortic  insufficiency. 

(3)  The  Propagation  of  Murmurs  and  the  Extent  of  the  Area 
in  which  they  can  be  Heard. — Murmurs  are  very  often  heard  over 
limited  areas  and  transmitted  in  definite  directions.  This  is  especially  but 
not  exclusively  true  of  the  murmurs  produced  by  lesions  of  single  "valve 
systems.  Thus  the  murmur  of  mitral  stenosis — the  presystolic  murmur — 
is  heard  over  a  circumscribed  area  just  above  the  apex  and  is  not  propa- 
gated, while  the  systolic  murmur  of  mitral  incompetence  is  heard  over  a 
considerable  area  to  the  right  of  the  apex  and  upward  and  is  transmitted 
distinctly  in  the  direction  of  the  left  axilla  and  to  the  back.  On  the  other 
hand  the  systolic  murmur  of  aortic  stenosis  is  usually  prolonged  and  loud, 
heard  over  an  extended  area  and  transmitted  into  the  carotid  and  sub- 
clavian artery;  it  is  in  some  instances  heard  at  a  distance  from  the  chest. 
The  diastolic  murmur  of  aortic  incompetence  may  also  be  heard  over  an 
extensive  area  of  the  chest  both  in  front  and  behind.  A  murmur  distinctly 
heard  over  two  or  more  valve  areas  may  be  due  to  one  or  to  several  valve 
lesions.  If  it  is  systolic  in  time,  it  may  be  the  sign  of  mitral  insufficiency 
or  of  aortic  stenosis,  or  the  murmur  may  be  a  compound  of  two  murmurs, 
each  representing  one  of  these  lesions.  The  difficulties  are  greatly  increased 
when  there  are  to-and-fro  murmurs  representing  double  lesions — stenosis 
and  incompetence — of  the  respective  valves.  A  correct  diagnosis  rests 
upon  the  application,  in  the  study  of  individual  cases,  of  the  knowledge, 
obtained  by  clinical  experience  and  post-mortem  examination,  that  the 
murmur  produced  by  each  valvular  lesion  has  its  characteristic  point  of 
maximum  intensity  and  definite  line  of  propagation  along  which  its  inten- 
sity gradually  diminishes  as  the  stethoscope  is  moved  away  from  that 
point.  A  murmur  which  fulfils  these  requirements  in  regard  to  a  particular 
valve  area  and  line  of  propagation  and  is  unaccompanied  by  any  other 
murmur  ma}7  be  regarded  as  the  sign  of  a  lesion  of  that  valve.  When, 
however,  two  or  more  murmurs  are  heard  which  differ  in  their  acoustic 
characters,  as  pitch,  quality,  and  duration,  and  present  each  its  point  of 
maximum  intensity,  and  are  propagated  respectively  in  different  direc- 
tions, a  correct  diagnosis  can  only  be  reached  by  the  separate  study  of 
each  as  though  it  alone  were  present,  the  others  being  for  the  time  being 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  193 

disregarded.  In  this  analytical  study  too  much  importance  cannot  be 
placed  upon  the  differences  in  pitch  and  quality  and  the  evidences  of  the 
influence  of  the  lesions  which  cause  the  murmurs,  upon  the  size  of  the  heart, 
the  viscera  and  the  pulmonary  and  peripheral  circulation.  In  compli- 
cated cases  of  cardiac  disease  the  diagnosis  cannot  be  made  by  an  analysis 
of  the  murmurs  alone.  A  systematic  study  of  the  associated  physical  signs 
is  essential  to  success. 

When  several  murmurs  are  present,  it  is  best  not  to  attempt  an  over- 
refined  diagnosis  in  regard  to  the  lesions  which  underlie  all  of  them.  We 
may  be  content  when  we  have  determined  with  accuracy  the  two  which 
are  most  important,  and  we  may  be  reconciled  to  our  inability  to  satis- 
factorily do  more  than  this  by  the  knowledge  that  greater  nicety  of  diag- 
nosis, though  it  might  gratify  our  technical  ambition,  is  not  demanded 
by  the  requirements  of  therapeutics  and  prognosis,  and  has  been  dis- 
credited by  the  experience  of  the  post-mortem  room. 

In  this  connection  it  is  important  to  call  the  attention  of  the  student 
to  the  fact  that  the  intensity  of  a  murmur  does  not  necessarily  gradually 
and  progressively  diminish  in  its  line  of  propagation,  but  may  be  modified 
by  the  presence  of  a  viscus  or  the  interposition  of  a  new  growth.  Thus  an 
aortic  murmur  may  be  distinctly  heard  in  the  aortic  area  and  near  the  apex 
and  only  faintly  in  the  intervening  space.  This  phenomenon  has  been 
attributed  to  the  interposition  of  the  right  ventricle,  while  the  transmission 
of  a  mitral  regurgitant  in  the  direction  of  the  left  axilla  may  be  abruptly 
interrupted  by  a  pleural  effusion  or  neoplasm. 

(4)  The  Relation  of  Murmurs  to  the  Sounds  of  the  Heart. — A 
murmur  may  accompany  the  sounds  of  the  heart  or  may  replace  them. 
The  systolic  apex  murmur  of  mitral  incompetence  wholly  or  in  part 
replaces  the  first  sound.  The  systolic  basic  murmur  of  aortic  stenosis 
accompanies  the  first  sound,  but  when  compensation  fails  the  first  sound 
is  greatly  weakened,  and  with  enfeeblement  and  dilatation  of  the  ventricle 
or  upon  the  supervention  of  relative  mitral  incompetence  it  may  no  longer 
be  heard.  In  aortic  stenosis  the  second  sound  is  not  often  heard  at  the 
aortic  cartilage,  because  the  deformity  of  the  valve  usually  prevents  its 
closure.  In  aortic  incompetence,  the  second  sound  may  be  well  heard  or  it 
may  be  replaced  by  the  murmur.  In  some  cases  it  may  be  absent  in  the 
aortic  area  but  heard  over  the  carotid  artery. 

A  murmur  which  accompanies  a  sound  also  follows  it,  since  the  time 
of  the  murmur  is  longer  than  that  of  the  sound.  A  murmur  may  run  up 
io  a  sound,  as  the  presystolic  murmur  of  mitral  stenosis.  In  rare  cases 
murmurs  occur  between  the  sounds.  The  persistence  of  the  sound  along 
with  the  murmur  may  be  of  favorable  prognostic  significance,  as,  for 
example,  in  aortic  incompetence,  where  it  indicates  partial  closure  of  the 
damaged  valve  cusps  with  corresponding  preservation  .if  function. 

(5)  'I'm;  ACOUSTIC  Properties  of  Mfumfhs.—  Under  this  caption  the 
(a)  intensity,  (b)  quality,  (c)  pitch,  and  (d)  duration  of  murmurs  are  to  be 
considered. 

(a)    /utensil;/.  —  The  intensity  of  cardiac  murmurs  is  extremely  variable. 
A  murmur   may  be  so  loud   that    it    may   be   heard   al    a   distance  of  some 
feet,  or  so  low  as  to  be  scarcely  audible  when  the  patienl  holds  his  breath. 
13 


194  MEDICAL  DIAGNOSIS. 

Not  infrequently  a  loud  murmur  is  heard  by  the  patient  himself.  Such  very 
loud  murmurs  are  rare.  The  intensity  of  a  murmur  is  by  no  means  pro- 
portionate to  the  gravity  of  the  lesion  by  which  it  is  produced.  On  the 
contrary,  since  its  intensity  depends  upon  the  energy  with  which  the  blood 
is  propelled  through  the  affected  orifice,  that  is,  upon  the  compensation,  a 
loud  murmur  is,  other  things  being  equal,  more  favorable  than  a  faint  one. 
As  compensation  fails,  the  murmur  becomes  fainter  and  it  not  infrequently 
happens  that  in  patients  coming  under  observation  with  greatly  impaired 
compensation  no  murmur  can  be  recognized  upon  careful  auscultation, 
but  after  rest  and  suitable  treatment  have  brought  about  inprovement  in 
the  general  condition  and  in  compensation  a  murmur  appears  which 
becomes  more  intense  as  the  patient  grows  better.  This  is  especially 
the  case  in  mitral  disease.  There  are,  however,  cases  of  acute  rheumatic 
endocarditis,  especially  in  children,  and  of  malignant  endocarditis  in 
which  the  changes  in  the  valvular  lesions  develop  rapidly  while  the  power 
of  the  myocardium  is  still  maintained,  in  which  increasing  loudness  of  the 
murmur  constitutes  a  most  unfavorable  sign.  The  intensity  of  an  organic, 
endocardial  murmur  is  important  less  from  its  degree  at  any  one  time  than 
from  its  decrease  or  increase  during  the  progress  of  the  case. 

A  murmur  is  not  usually  of  the  same  intensity  during  its  brief  course. 
In  general  it  is  louder  at  the  beginning  than  at  the  end.  Presystolic  mur- 
murs are,  however,  usually  louder  at  the  close.  The  cause  of  the  increase 
in  intensity  is  here  due  to  the  fact  that  the  blood  flows  gently  through  the 
auriculo ventricular  orifice  at  the  beginning  of  the  ventricular  diastole, 
but  with  increased  force  under  the  stress  of  the  auricular  contraction  later. 

(b)  Quality. — Endocardial  murmurs  vary  in  quality  from  a  soft  blow- 
ing sound  —  bellows  murmur,  souffle — of  little  intensity,  to  a  coarse, 
harsh,  rasping  sound  of  considerable  loudness.  In  rare  instances  they 
are  musical.  The  musical  quality  is  usually  manifest  during  a  part  of 
the  murmur  only,  the  remainder  having  the  ordinary  blowing  or  rasping 
character.  The  musical  quality  indicates  an  organic  lesion,  but  does  not 
enable  us  to  define  its  nature  and  is  without  significance  in  prognosis 
except  that  it  indicates  a  certain  degree  of  power  in  the  heart  muscle.  The 
presystolic  murmurs  which  are  produced  by  mitral  and  tricuspid  stenosis 
and  the  "Flint  murmur"  of  aortic  insufficiency  have  a  peculiar  "rum- 
bling" or  "blubbering"  quality  not  heard  under  other  conditions.  These 
murmurs  have  been  compared  to  a  short  roll  of  the  drum,  but  they  are 
much  less  regular. 

(c)  Pitch. — This  attribute  of  murmurs  is  also  variable.  Blowing 
murmurs  of  soft  quality  are  commonly  low  pitched,  while  the  coarser 
murmurs  are  often  high  in  pitch:  to  this  general  statement  the  excep- 
tion that  the  very  coarse,  blubbering  presystolic  murmurs  are  usually 
of  low  pitch.  It  is  the  high-pitched  murmur  that  tends  to  assume  the 
musical  quality. 

(d)  Duration. — A  murmur  may  occupy  the  whole  period  of  the  systole 
or  the  diastole  or  any  part  of  either  of  these  periods.  The  systolic  murmur 
of  mitral  incompetence  is  sometimes  prolonged,  the  diastolic  murmur  of 
aortic  incompetence  almost  always  so.  Presystolic  murmurs  are  of  shorter 
duration     The  length  of  murmurs  is  not  of  itself  of  prognostic  significance 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  195 

(e)  Variation  in  Murmurs. — Rapid  changes  in  the  acoustic  properties  of 
murmurs,  even  their  disappearance  and  reappearance,  may  occur  in  acute 
endocarditis  when  vegetations  are  forming  upon  the  valve  segments,  and 
especially  in  the  malignant  form,  in  which  the  vegetations  grow  with  rapidity 
upon  the  valves  and  adjacent  walls  and  ulcerative  lesions  occur.  Similar 
changes  may  occur  in  the  course  of  acute  endocarditis  as  the  result  of 
rupture  of  chordae  tendinese  or  the  formation  of  adhesions  between  valve 
segments  or  between  a  segment  and  the  wall  of  the  heart. 

(6)  Effects  of  Exercise,  Respiration*,  and  Posture  upon  Endo- 
cardial Murmurs. — Faint  murmurs  usually  become  more  distinct  upon 
moderate  exercise,  as  walking  rapidly  two  or  three  times  across  a  room,  or 
stooping  and  rising  several  times  in  succession,  and  these  movements  are 
sometimes  necessary  in  the  examination  of  doubtful  cases.  When,  how- 
ever, a  murmur  has  grown  indistinct  or  disappeared  as  the  result  of  rupture 
of  compensation,  movement  simply  increases  the  cardiac  dyscrasia. 

Organic  murmurs  are  usually  more  distinctly  audible  upon  quiet 
breathing,  or  while  respiration  is  momentarily  suspended,  and  at  the  close  of 
expiration,  when  a  larger  area  of  the  heart  is  uncovered.  In  this  respect 
they  differ  from  functional  murmurs,  which  are  frequently  best  heard  upon 
inspiration. 

Posture  exerts  an  important  influence  upon  the  intensity  of  certain 
murmurs.  Systolic  murmurs  not  heard  in  the  upright  position  may  be 
distinctly  audible  in  recumbency;  on  the  other  hand,  murmurs  not  heard 
in  the  recumbent  posture  may  be  recognized  when,  by  the  patient 
leaning  forward,  the  heart  is  brought  into  closer  relation  with  the  wall 
of  the  thorax.  Presystolic  murmurs  are  sometimes  much  better  heard  in 
the  erect  than  in  the  recumbent  posture. 

The  Significance  of  Functional,  Accidental,  or  Ha?mic  Murmurs. — A  large 
proportion  of  endocardial  murmurs,  much  larger  than  was  formerly 
supposed,  are  not  associated  with  anatomical  cardiac  lesions.  Certainly 
murmurs  are  not  rarely  heard  intra  vitam  in  cases  in  which  no  corresponding 
valvular  lesions  are  found  post  mortem.  Systolic  murmurs  arising  in  condi- 
tions of  cardiac  asthenia  from  relaxation  of  the  cardiac  sphincter— rela- 
tive incompetence — and  having  all  the  characters  of  incompetence  from 
actual  lesions  at  the  mitral  orifice,  though  often  transient  are  not  usually 
described  us  "  funct ional."  Short,  whirring,  systolic  murmurs,  sometimes 
heard  in  the  mitral  area  directly  after  violent  or  prolonged  physical  effort, 
are  probably  due  to  relative  insufficiency  resulting  from  acute  dilatation. 
They  disappear  in  the  course  of  a  little  time. 

Functional  murmurs  are  almost  always  systolic  in  time.  By  far  the 
greater  number  of  them  have  their  point  of  maximum  intensity  in  the 
pulmonic  area;  occasionally  only  are  they  most  distinctly  heard  in  the 
aortic  or  mitral  areas.  They  are  commonly  well  heard  to  a  little  distance 
from  the  point  of  maximum  intensity  in  all  directions  rapidly  diminishing 
in  loudness,  and  are  no!  distinctly  transmitted  in  a  definite  line,  as  is  usual 
with  organic  murmurs.  They  are  as  a  rule  soft  and  blowing  in  character. 
A  loud  coarse  murmur,  whatever  its  other  points  of  resemblance  to  func- 
tional murmurs,  is  likely  to  prove  to  be  organic,  especially  when  persistent. 
Functional   murmurs  are  usually  most  distinct  at  the  close  of  inspiration. 


196  MEDICAL  DIAGNOSIS. 

They  are  commonly  transient  and  disappear  when  the  condition  with 
which  they  are  associated  improves.  They  are  not  associated  with  the 
signs  of  enlargement  of  the  heart  or  with  accentuation  of  the  pulmonary 
second  sound. 

Functional  murmurs  are  significant  of  the  various  forms  of  anaemia. 
For  this  reason  they  are  spoken  of  as  "haemic  murmurs."  They  occur  in 
secondary  anaemias,  chlorosis,  pernicious  anaemia,  leukaemia  and  Hodgkin's 
disease.  A  distinct,  prolonged  systolic  murmur  in  the  pulmonary  area  is 
common  in  chlorosis,  and,  in  consequence  of  the  retraction  of  the  bor- 
ders of  the  lungs,  is  frequently  associated  with  a  loud  pulmonary  second 
sound.  In  the  stadium  ultimum  of  pernicious  anaemia  the  haemic 
murmurs  often  disappear. 

The  differential  diagnosis  between  organic  and  functional  endocardial 
murmurs  rests  upon  the  following  facts: 

Organic  murmurs  occur  at  any  period  in  the  revolution  of  the  heart; 
functional  murmurs  are  practically  always  systolic.  It  becomes  necessary, 
therefore,  to  contrast  the  characters  of  organic  systolic  murmurs  with  those 
of  functional  murmurs. 

Systolic  organic  murmurs  are  usually  well  propagated  in  the  case  of 
mitral  insufficiency  toward  the  left  axilla  and  to  the  back;  in  aortic 
stenosis,  to  the  carotids  and  the  subclavians,  especially  upon  the  right  side. 
They  are  often  soft  and  blowing,  not  rarely  coarse  and  loud,  sometimes 
musical.  The  point  of  maximum  intensity  corresponds  to  the  respective 
mitral  and  aortic  areas  as  above  described  (see  page  169),  and  only  in  excep- 
tional cases  is  to  be  located  in  the  neighborhood  of  the  pulmonary  area. 
Organic  murmurs,  except  in  the  case  of  relative  insufficiency,  are  persist- 
ent, diminishing  in  intensity  and  ultimately  disappearing  only  when  the 
compensation  fails  and  is  finally  ruptured.  They  are  sooner  or  later  asso- 
ciated with  the  signs  of  enlargement  of  the  heart  and  increase  of  the  blood- 
pressure  in  the  veins,  as  accentuation  of  the  pulmonic  second  sound,  visceral 
engorgement  and  anasarca.  The  anamnesis  commonly  points  to  an  acute 
infection,  rheumatic  fever,  hard  work  and  worry  as  causal  factors. 

Functional  murmurs,  on  the  other  hand,  are  not  propagated  in  definite 
directions;  practically  always  soft  and  blowing,  very  exceptionally  loud  or 
coarse;  never  musical.  Their  point  of  maximum  intensity  is  almost  invari- 
ably in  the  pulmonic  area.  They  are  transient  and  not  associated  with 
the  signs  produced  by  the  effects  of  valvular  lesions,  as  manifest  in  retard- 
ation of  a  part  of  the  blood  stream;  accentuation  of  the  pulmonic  second 
sound,  enlargement  or  distention  of  the  walls  of  the  heart;  visceral  derange- 
ments— venous  engorgement;  or  disorders  of  the  peripheral  circulation 
— dropsy.     Anaemia  is  almost  always  present. 

The  rare  diastolic  functional  murmur,  so  rare  as  to  be  unimportant 
in  diagnosis,  has  been  observed  only  in  anaemia  of  very  high  grade  and  in 
association  with  a  venous  hum. 

B.  Exocardial  Adventitious  Sounds. — Morbid  physical  signs  not  hav- 
ing their  origin  within  the  heart  are  frequently  heard  upon  auscultation 
in  the  precordial  region.  Important  in  themselves,  they  acquire  addi- 
tional diagnostic  importance  by  reason  of  their  occasional  close  resemblance 
to  endocardial  murmurs.     Of  these  the  following  are  the  more  important. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  197 

(a)  Pericardial  Friction.  —  The  friction  rub  of  dry  or  fibrinous  peri- 
carditis is  heard  upon  auscultation  as  a  grazing,  creaking,  or  rasping  sound 
occupying  some  part  of  the  time  of  the  cardiac  revolution.  It  is  sometimes 
systolic,  sometimes  diastolic,  often  to-and-fro,  but  rarely  corresponds  to 
the  systole  or  diastole  as  endocardial  murmurs  do.  It  occurs  irregularly 
and  with  momentary  interruptions,  commonly  changes  in  character  and 
time  from  one  examination  to  another,  and  may  appear,  disappear,  and 
appear  again  in  the  course  of  a  few  hours.  Pericardial  friction  is  usually 
best  heard  in  the  area  of  superficial  cardiac  dulness,  but  may  be  heard  at 
any  part  of  the  precordial  region  and  sometimes  over  the  greater  part 
of  it.  In  some  instances  it  is  confined  to  the  base  of  the  heart.  It  is  alwavs, 
however,  distinctly  circumscribed  and  never  propagated  in  any  direction 
beyond  the  borders  of  the  heart.  It  conveys  the  impression  of  being  pro- 
duced close  to  the  ear  and  is  intensified  by  the  pressure  of  the  stethoscope, 
which  also  increases  the  pain  which  is  present.  It  is  apt  also  to  be  increased 
when  the  patient  inclines  his  body  forward.  It  is  little  influenced  by  the 
respiratory  movements,  except  that  in  some  instances  its  area  is  slightly 
extended  in  expiration.  Pericardial  friction  is  frequently  associated  with 
endocardial  murmurs,  the  signs  occurring  as  the  manifestations  of  an 
endopericarditis  or  the  pericarditis  developing  in  an  individual  already 
the  subject  of  chronic  valvular  disease.  Under  these  circumstances  the 
friction  sound  is  usually  more  conspicuous  than  the  endocardial  murmur 
and  at  times  may  mask  it  altogether. 

The  differential  diagnosis  between  an  endocardial  murmur  and  a 
pericardial  friction  rests  upon  a  critical  analysis  of  the  signs  in  the  light 
of  the  history  of  the  case. 

(b)  Pleuropericardial  Friction. — Cases  occasionally  occur  in  which  fibri- 
noid exudate  upon  that  part  of  the  pleura  which  is  in  relation  with  the 
pericardium  gives  rise  to  a  friction  sound  having  the  cardiac  rhythm,  the 
roughened  pleural  surfaces  being  moved  in  apposition  to  each  other  by  the 
movement  of  the  heart.  The  differential  diagnosis  between  pericardial 
and  pleuropericardial  friction  rests  upon  the  following  facts: 

The  pleuropericardial  friction  is  commonly  heard  in  connection  with 
a  friction  sound  having  also  the  respiratory  rhythm — pleural  friction. 
It  is  apt  to  be  increased  by  forced  respiratory  movements  and  to  be  more 
distinct  upon  inspiration,  whereas  pericardial  friction  is  best  heard  at  the 
close  of  expiration.     A  positive  diagnosis  cannot  always  be  made. 

(c)  Cardiopulmonary  Murmurs. —  Murmurs,  hitherto  known  as  cardio- 
respiratory, having  the  cardiac  rhythm,  are  occasionally  produced  in 
the  borders  of  the  lung  in  relation  with  the  heart  by  the  traction  or 
pulsion  of  the  heart  upon  the  lung  tissue  in  systole  or  diastole.  The  mur- 
murs arc  pulmonary  but  not  respiratory,  and  are  due  to  the  sudden  dis- 
placement of  a  certain  volume  of  air  from  a  mass  of  lung  tissue  confined 
by  adhesions.  They  are  mosl  commonly  heard  near  the  apex  of  the  heart 
and  over  the  projection  of  the  left  lung  which  overlaps  it.  known  as  the 
lingula;  less  often  under  the  left  clavicle  or  about  the  angle  of  the  left 
scapula.  These  murmurs  are  mostly  systolic — traction  murmurs;  very 
rarely  diastolic — pulsion  murmurs  and  are  heard  over  circumscribed 
areas.    They  are  much  influenced  by  active  respiration  and  cough.    They 


198  MEDICAL  DIAGNOSIS. 

occur  during  inspiration  and  are  scarcely,  if  at  all,  audible  during  expira-* 
tion,  a  fact  which  is  of  importance  in  distinguishing  them  from  endocardial 
murmurs,  which  are  usually  better  heard  when  the  breath  is  held  in  expira- 
tion and  a  larger  cardiac  surface  left  uncovered  by  the  retracted  lung. 
Cardiopulmonary  murmurs  have  the  soft,  breezy  quality  of  the  vesicular 
murmur  and  suggest  an  inspiratory  act  broken  by  successive  movements 
of  the  heart,  which  in  point  of  fact  they  are.  In  rare  instances  these  mur- 
murs are  accompanied  by  crepitant  or  subcrepitant  rales.  Their  importance 
from  the  standpoint  of  the  diagnostician  consists  in  their  superficial  resem- 
blance to  endocardial  murmurs,  from  which  they  may  be  differentiated 
without  difficulty. 

(d)  The  Precordial  Rales  of  Emphysema. — In  rare  cases  of  emphysema, 
in  consequence  of  the  rupture  of  the  walls  of  vesicles,  air  finds  its  way 
along  the  interstitial  tissue  to  the  root  of  the  lung  and  thence  to  the 
connective  tissue  of  the  anterior  mediastinum.  The  superficial  cardiac 
dulness,  if  not  previously  obliterated  by  the  borders  of  the  emphysematous 
lung,  disappears  with  weakening  of  the  heart  sounds  and  the  occurrence  of 
high-pitched  metallic  or  crepitant  rales  which  have  the  rhythm  of  the 
heart.  These  signs  are  to  be  differentiated  by  their  acoustic  properties 
from  the  tricuspid  regurgitant  murmurs,  due  to  the  dilatation  of  the  right 
ventricle,  so  frequently  heard  in  emphysema.  They  are  also  to  be  differ- 
entiated from  the  rales  having  the  cardiac  rhythm,  which  are  heard  in  rare 
cases  of  infiltration  of  the  lungs  or  cavity  formation  in  the  neighborhood  of 
the  heart,  by  the  persistence  in  the  latter  of  superficial  cardiac  dulness  and 
the  heart  sounds,  the  character  of  the  associated  respiratory  sounds,  and  by 
the  fact  of  their  occurrence  in  pulmonary  emphysema. 

(e)  Pericardial  Splashing. — In  pneumohydro-  or  pneumopyo-pericar- 
dium  there  may  be  heard  peculiar  splashing  sounds  of  metallic  character 
similar  to  the  succussiom  sounds  of  pneumohydrothorax,  but  having  the 
cardiac  rhythm.  The  heart  sounds  under  these  circumstances  are  usually 
feeble  and  distant.  The  cardiac  dulness  is  in  the  recumbent  posture 
replaced  by  an  area  of  tympany,  the  borders  of  which  shift  with  changes  in 
the  posture  of  the  patient.  These  splashing  sounds  can  under  no  circum- 
stances be  mistaken  for  murmurs,  but  they  may  closely  resemble  the  splash- 
ing of  the  gastric  contents  sometimes  produced  by  the  movements  of  the 
heart,  or  that  of  pneumothorax  or  of  a  large  vomica,  from  which  they  may, 
however,  be  distinguished  by  the  gravity  of  the  symptoms,  the  concomi- 
tant signs  of  pericardial  perforation  or  inflammation,  the  examination  of 
the  patient  when  the  stomach  is  empty,  or  a  systematic  routine  examina- 
tion of  the  lungs. 

(f)  The  Murmurs  of  Aneurisms. — Aneurism  of  the  thoracic  aorta  more 
commonly  involves  the  ascending  portion  of  the  arch.  On  auscultation 
at  the  base  of  the  heart  or  sometimes  in  a  wide  area  there  may  be  heard  a 
systolic  murmur,  transmitted  like  the  murmur  of  aortic  stenosis  in  the 
direction  of  the  aorta  itself  and  the  vessels  of  the  neck.  A  diastolic  mur- 
mur is  sometimes  also  present.  The  latter  is  due  to  the  reflux  of  blood  into 
the  sac,  and  may  easily  be  mistaken  for  the  murmur  of  aortic  insufficiency 
with  which  it  is  not  infrequently  associated,  as  the  manifestation  of  relative 
incompetence  in  consequence  of  the  dilatation  of  the  aorta  or  of  valvular 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  199 

deformities  resulting  from  sclerotic  changes.  The  differential  diagnosis 
rests  upon  the  presence  or  absence  of  the  signs  of  aneurism,  as  deter- 
mined by  systematic  inspection,  palpation,  percussion,  and  the  anamnesis. 

SOUNDS  HEARD  OVER  THE  PERIPHERAL  VESSELS. 

Auscultation  of  the  Arteries.  Normal  Conditions. — When  the  steth- 
oscope is  lightly  placed  over  the  larger  arteries  where  they  run  superficially, 
sounds  may  be  heard  which  correspond  to  the  sounds  of  the  heart.  These 
sounds  are  produced  (a)  in  the  heart  and  (b)  in  the  arteries  themselves. 

The  carotid  may  be  studied  at  the  angle  of  the  jaw  or  at  the  inner 
border  of  the  sternocleidomastoid  muscle;  the  subclavian  directly  above 
the  clavicle  and  external  to  the  sternocleido  muscle  or  directly  below  it, 
in  the  arm  between  the  pectoralis  major  and  the  deltoid;  the  brachial 
at  the  inner  border  of  the  biceps  or  at  the  bend  of  the  elbow,  the  arm  being 
slightly  flexed;  the  radial  just  above  the  wrist,  and  the  femoral  immediately 
below  Poupart's  ligament. 

(a)  The  normal  heart  sounds  are  transmitted  to  some  distance  along 
the  course  of  the  main  arteries  at  the  root  of  the  neck  and  may  be  heard 
in  adults  over  the  carotids  and  subclavians,  more  distinctly  upon  the  right 
than  upon  the  left  side.  In  infancy  and  childhood  only  the  second  sound 
is  thus  transmitted,  the  first  being  very  indistinct  or  wholly  inaudible. 

(b)  A  systolic  sound,  due  to  the  sudden  tension  of  the  arterial  walls, 
may  in  some  cases  be  heard  over  the  abdominal  aorta  and  the  femorals. 
In  the  majority  of  cases  no  sound  is  heard  over  these  vessels  nor  over  the 
smaller  superficial  arteries  so  long  as  the  stethoscope  is  applied  without 
pressure.  When,  however,  some  degree  of  pressure  is  exerted  upon  the 
wall  of  the  artery  by  the  rim  of  the  stethoscope,  a  systolic  murmur  is  pro- 
duced, often  intense  and  high-pitched,  the  so-called  compression  murmur. 
This  murmur  is  due  to  sudden  narrowing  of  the  lumen  of  the  vessel  at  the 
point  of  pressure  with  the  production  of  fluid  veins.  If  the  pressure  is 
increased  to  such  a  degree  as  to  obliterate  the  lumen  of  the  artery  a  sys- 
tolic sound  is  produced  by  the  increased  force  of  the  tension  of  the  arterial 
wall — pressure  sound.  These  phenomena  are  physiological  and  without 
other  clinical  significance  than  that  which  attends  the  risk  of  attaching 
erroneous  importance  to  them. 

(c)  Intracranial  Murmurs. — In  children  up  to  the  sixth  year  there 
is  sometimes  to  be  heard  upon  auscultation  over  the  cranium,  and  especially 
over  the  anterior  fontanelle  and  in  the  parietal  regions,  a  distinct  systolic 
murmur,  which  apparently  originates  in  the  internal  carotids  from  some 
unknown  cause  and  is  without  diagnostic  significance. 

(d)  The  Uterine  Souffle. — A  soft  blowing  systolic  murmur  is  heard 
over  the  pregnant  uterus.  It  is  first  heard  about  the  end  of  the  sixteenth 
week  and  increases  in  frequency  until  the  eighth  month,  after  which  it 
remains  stationary.  This  murmur  is  subject  to  great  variation  as  regards 
quality,  intensity,  rhythm,  and  point  of  maximum  intensity.  It  is  usually 
most  distinct  low  down  and  upon  one  or  the  other  side  of  the  uterus,  some- 
times at  the  fundus,  but  very  rarely  over  the  entire  uterine  body.  It  is 
attributed  to  the  circulation  of  the  blood  in  the  arteries  of  the  uterine 


200  MEDICAL  DIAGNOSIS. 

wall.  The  diagnostic  importance  of  this  sign  is  impaired  by  the  fact  that 
a  similar  murmur  is  occasionally  heard  in  chronic  metritis,  uterine  myomata, 
and  ovarian  cysts. 

Single  or  double  murmurs  corresponding  in  time  to  the  fetal  heart- 
beats are  sometimes  recognized  in  auscultation  in  pregnancy.  They  have 
in  some  instances  been  found  to  be  associated  with  defects  of  development 
or  endocardial  lesions  of  the  fetal  heart — cardiac  souffle.  In  other  cases 
murmurs  have  originated  in   the   umbilical   cord — funic  murmurs. 

Auscultation  of  the  Arteries.  Pathological  Conditions. — (a)  It  is 
obvious  that  abnormal  sounds — murmurs — heard  in  the  aorta  will  be 
transmitted  into  the  carotids  and  subclavians.  The  systolic  and  less 
intensely  the  diastolic  murmurs  of  lesions  of  the  aortic  valve  system 
are.  transmitted  along  the  course  of  these  vessels. 

(b)  In  any  condition  in  which  the  pulse  is  quick — -pulsus  celer — the 
arteries  may  yield  upon  auscultation  a  systolic  sound.  This  sign  is  some- 
times present  in  fever  and  is  common  in  aortic  insufficiency,  and  may  be 
heard  over  the  radials  as  well  as  over  arteries  of  larger  calibre.  In  aortic 
insufficiency  of  high  grade  a  double  sound  is  sometimes  heard  over  the 
femorals,  the  systolic  dilatation  and  the  diastolic  contraction  of  the  artery 
being  alike  attended  with  an  audible  sound.  Systolic  and  diastolic  sounds 
in  the  femoral  artery  have  also  been  observed  in  pregnancy  and  in  chronic 
lead  poisoning. 

(c)  Double  Murmurs  in  the  Arteries.  Duroziez's  Murmurs. — In  well- 
marked  cases  of  expansile  pulse  in  which  the  blood  wave  rises  rapidly 
and  rapidly  recedes  there  may  frequently  be  detected  over  the  femoral 
or  brachial  artery  at  a  certain  point  in  the  gradually  increased  pressure  of 
the  stethoscope  a  double — namely,  systolic  and  diastolic — murmur.  Some 
care  is  necessary  to  exert  the  degree  of  pressure  under  which  this  sign  is 
best  heard.  It  may  be,  observed  in  aortic  insufficiency,  chlorosis,  and 
other  conditions  in  which  there  is  well-marked  pulsus  celer. 

(d)  Subclavian  Murmurs. — Systolic  murmurs  occurring  independently 
of  pressure  by  the  stethoscope  are  common.  Heard  upon  one  side  only 
when  the  attitude  of  the  patient  is  unconstrained  and  the  arms  hanging 
at  the  sides,  such  a  murmur  is  very  suggestive  of  apex  disease  of  the  lung 
with  pleural  adhesions  implicating  the  artery  in  its  course.  They  are 
commonly  louder  upon  inspiration,  exceptionally  upon  expiration.  Such 
murmurs  are  occasionally  to  be  heard  upon  one  or  both  sides  in  normal 
individuals,  and  there  are  those  who  are  able  to  produce  them  at  will 
by  assuming  certain  attitudes,  with  fixation  of  the  arms  and  the  muscles 
of  the  upper  part  of  the  chest. 

(e)  Thyroid  Murmurs. — Systolic  murmurs  are  very  common  over  the 
enlarged  and  tortuous  arteries  in  goitre  and  especially  in  Graves's  disease. 

(f)  Murmurs  in  Local  Arteriosclerosis  in  Superficial  Arteries. — Sys- 
tolic murmurs  due  to  this  cause  are  occasionally  observed.  They  are 
audible  in  some  cases  without  pressure  by  the  stethoscope;  in  others  upon 
a  minimum  pressure.     They  are  most  common  in  the  carotids. 

Auscultation  of  the  Veins.  Normal  Conditions. — In  healthy  individ- 
uals the  blood  flows  in  the  veins  without  sound  or  murmur.  In  rare  instances 
the  occurrence  of  a  venous  hum  constitutes  an  exception  to  this  rule. 


PHYSICAL  DIAGNOSIS  :    AUSCULTATION.  201 

Auscultation  of  the  Veins.  Pathological  Conditions. — (a)  The  venous 
pulse  in  tricuspid  insufficiency  may  by  sudden  tension  of  the  valves  and 
walls  of  the  jugular,  and  in  particular  the  valves  of  the  bulb,  give  rise  to 
a  systolic  sound  which  is  scarcely  to  be  distinguished  from  the  almost 
synchronous  systolic  carotid  sound,  except  by  the  fact  that  it  slightly 
precedes  it. 

(b)  Venous  Hum — Nun's  Murmur. — This  is  the  single  venous  murmur 
of  practical  diagnostic  importance.  Since  the  return  flow  of  the  venous 
blood   is   to    all   intents   uninterrupted,   venous  murmurs  are  continuous. 

The  patient  should  assume  the  upright  posture  with  the  head  straight. 
The  stethoscope  should  be  placed  over  the  space  between  the  sternal  and 
clavicular  portions  of  the  sternocleidomastoid  muscle  without  pressure. 
The  murmur  in  question  when  present  is  heard  as  a  peculiar,  sometimes 
blowing,  sometimes  coarse  and  humming  or  again  musical  continuous 
sound,  with  rhythmical  systolic,  diastolic,  and  inspiratory  intensifications. 
It  is  best  heard  upon  the  right  side  and  diminishes  in  loudness  or  entirely 
disappears  when  the  patient  assumes  the  recumbent  posture.  Rotation 
of  the  face  toward  the  opposite  side  increases  the  intensity  of  the  sound. 
Pressure  with  the  stethoscope  at  first  increases  then  enfeebles  the  murmur 
until  it  wholly  ceases  and  the  systolic  sound  of  the  carotid  is  heard.  In 
some  cases  a  feeble  murmur  loses  its  continuous  character  and  is  perceived 
only  at  the  moment  of  systole,  diastole,  or  during  inspiration.  Under 
these  circumstances  the  murmur  becomes  continuous  upon  light  pressure 
with  the  stethoscope  or  if  the  head  is  rotated  toward  the  opposite  side — 
manoeuvres  which  enable  the  diagnostician  to  distinguish  the  murmur 
from  arterial  and  inspiratory  murmurs.  In  other  cases  the  diastolic  por- 
tion of  the  murmur  may  be  transmitted  to  the  base  of  the  heart  and  heard 
there  as  a  diastolic  murmur  apparently  of  endocardial  origin.  The  differ- 
ential diagnosis  may  be  attended  with  difficulty  unless  auscultation  is 
practised  from  point  to  point  from  the  heart  along  the  course  of  the  jugular, 
when  it  will  become  clearly  apparent  that  the  diastolic  murmur  hoard  over 
the  base  of  the  heart  is  in  point  of  fact  the  transmitted  venous  hum.  The 
venous  hum  occurs  in  anaemic  and  chlorotic  persons  and  occasionally  in 
healthy  individuals  with  normal  blood.  In  the  last  it  has  been  assumed 
thai  the  phenomenon  is  due  to  some  anatomical  peculiarity, as, for  instance, 
sudden  and  unusual  widening  of  the  jugular  at  the  bulb. 

In  general  terms  the  causes  of  the  venous  hum  are  the  more  rapid 
flow  of  the  blood  current  by  reason  of  its  lowered  specific  gravity  and  defi- 
cient haemoglobin,  and  the  sudden  widening  of  the  jugular  at  the  bull). 
The  fact  that  this  murmur  is  louder  in  the  erect  posture  is  rightly  ascribed 
to  the  influence  of  gravity  in  hastening  the  flow:    the  increased  intensity 

upon  inspiration  to  the  aspiration  exerted  by  the  chest  movement  at  that 
time,  and  the  greater  loudness  upon  the  right  side  to  the  more  direct  and 
unrestrained  flow  of  the  blood  arising  from  differences  in  the  anatomical 
arrangement  of  the  veins  of  the  two  sides. 


202  MEDICAL  DIAGNOSIS. 


III. 
THE  EXAMINATION  OP  THE  STOMACH  AND  INTESTINES.1 

General  Considerations. — Diseases  of  these  organs  are  (a)  primary  or 
organic  and  (b)  secondary  or  symptomatic,  and  in  each  of  these  groups 
there  are  cases  in  which  recognizable  anatomical  lesions  are  present  and 
cases  in  which  there  is  merely  derangement  of  function.  Thus,  carcinoma 
and  ulcers  are  examples  of  organic  disease  with  characteristic  lesions,  and 
hyperchlorhyclria  and  pyloric  spasm  are  functional  affections;  while  loss 
of  appetite,  eructations,  and  vomiting  occur  as  symptoms  of  phthisis, 
often  without  actual  lesions  of  the  stomach,  and  erosion  and  ulcer  are 
not  infrequent  in  chlorosis.  It  is  of  cardinal  importance  that  the  differ- 
ential diagnosis  between  organic  and  functional  disease  of  the  stomach 
and  intestines  should  in  all  cases  be  made,  particularly  as  the  former 
only  require  direct  local  treatment  and  the  latter  are  frequently  made 
worse  by  such  treatment. 

The  Anamnesis. — It  is  very  common  for  patients  to  attribute  to 
"stomach  trouble"  or  "bowel  trouble"  symptoms  due  to  diseases  of  other 
organs  or  to  constitutional  disease.  A  careful  and  systematic  anamnesis 
is  therefore  necessary  in  all  cases. 

Status  Prsesens. — The  actual  condition  is  ascertained  by,  (a)  physical 
examination,  with  special  modifications,  as  inflation,  transillumination, 
the  Rontgen  rays;  (b)  chemical,  and  (c)  microscopic  examination  of  the 
gastric  contents  and  alvine  discharges. 

EXAMINATION  OF  THE  STOMACH. 

(a)  Physical  Examination. — Inspection. — The  neck,  thorax  and 
whole  abdomen  should  be  exposed,  and  the  patient  studied  in  the  erect  as 
well  as  in  the  recumbent  posture.  In  the  neck  may  sometimes  be  seen  the 
enlarged  left  supra-clavicular  lymph-node  in  cases  of  carcinoma  of  the  sub- 
diaphragmatic viscera,  The  general  conformation  of  the  thorax  and  abdomen, 
the  type  of  epigastric  angle  and  the  number  of  floating  ribs  are  studied, 
and  in  some  cases  the  flaring  of  the  left  costal  arch  from  the  pressure  of  a 
distended  high-placed  stomach.  When  the  abdominal  wall  is  thin  and 
relaxed  the  outline  of  the  distended  stomach,  the  slow,  large  movements  of 
gastric  peristalsis  from  left  to  right,  far  more  rarely  reverse  peristalsis,  the 
presence  of  tumor  masses  in  the  gastric  wall  or  at  the  pylorus,  or  of  metastatic 
growths  about  the  umbilicus,  in  the  liver,  or  elsewhere,  may  be  observed. 
The  normal  pylorus  is  never  visible. 

Palpation. — This  method  is  useful  in  determining  localized  or  general 
tenderness,  rigidity,  the  presence  of  a  tumor,  enlargements  and  displacements 
of  the  stomach,  and  "splashing."  The  stomach  should  be  palpated  system- 
atically with  both  hands  and  for  several  minutes.  By  this  means  peristalsis 
may  be  aroused  and  a  tumor  which  is  not  otherwise  recognizable  brought 
within  reach.     Under  normal  conditions  the  pylorus  is  not  palpable,  being 

i  Originally  contributed  by  Dr.  Gwyn. 


THE  STOMACH  AND  INTESTINES. 


203 


separated  from  the  anterior  abdominal  wall  by  the  overlapping  liver,  when 
the  stomach  is  empty.  When  it  is  prolapsed  or  the  liver  is  small  or  in 
emaciated  persons,  the  pylorus  may  be  felt  as  an  elongated,  thickened  mass 
the  size  of  the  thumb,  extending  obliquely  to  the  right  and  upward  some- 
what above  the  level  of  the  umbilicus  beneath  the  right  rectus  muscle.  It 
may  be  recognized  by  frequent  rapid  changes  in  its  consistence  and  the 
palpable  and  sometimes  audible  forcible  passage  of  the  stomach  contents 
through  it  from  left  to  right.  Succussion  or  "splashing"  may  be  recognized 
both  by  the  palpating  hand  and  by  the  ear.  It  occurs  in  motor  insufficiency 
and  is  of  diagnostic  value  when  elicited  after  a  fasting  period  of  several 
hours.  The  patient  should  be  in  the  dorsal  posture  with  the  head  and 
shoulders  slightly  elevated,  and  at  the  moment  the  examination  is  made 
the  stomach  should  be  depressed  by  deep-held  inspiration.  The  examiner 
exerts  pressure  upon  the  epigastrium  at  the  level  of  the  xyphoid  appendix 


Fig.  82. — Palpating  the  abdomen. — Cohnheim. 

and  with  the  finger-tips  of  the  other  hand  makes  quick  pressing  movements 
immediately  followed  by  relaxation. 

Percussion. — This  method  is  of  little  value  by  itself.  The  stomach 
and  adjacent  coils  of  intestines  yield  tympanitic  resonance  or,  when  they 
contain  fluid  or  solid  matter,  dulness,  and  their  boundary  lines  cannot  be 
defined  by  ordinary  percussion.  Auscultatory  percussion,  especially  when 
the  stomach  is  inflated,  is  of  use.  The  percussion  should  be  performed  in 
lines  radiating  from  a  centre  over  the  stomach  and  the  points  of  change  in 
the  auscultatory  phenomena  marked  upon  each  line  in  turn.  Those  points 
are  then  connected.  Control  observations  may  be  made  by  changing  the 
centre  and  repeating  the  observation. 

Auscultation  has  only  a  limited  application  in  the  examination  of  the 
stomach.  It  is  employed  in  the  study  of  deglutition  phenomena,  '"splash- 
ing," the  8pHtzgerau8ch  of  pyloric  stenosis  and  hour-glass  contraction 
of  the  stomach.  In  the  last,  if  the  narrowing  be  of  high  degree,  there 
may  be  an  audible  sound  produced  by  the  passage  of  water  from  the  cardiac 
to  the  pyloric  loculus.  especially  if  pressure  be  used. 


204  MEDICAL  DIAGNOSIS. 

The  Swallowing  Test. — This  test  is  used  to  determine  the  patency 
of  the  cardiac  orifice  and  is  performed  in  the  following  manner:  The  ear 
or  the  bell  of  a  stethoscope  is  placed  at  the  left  of  the  tip  of  the  ensiform 
cartilage  or,  better,  at  the  left  of  the  seventh  thoracic  vertebra  of  the 
patient,  standing,  who  is  directed  to  take  a  mouthful  of  water  and  swallow. 
There  is  at  once  heard  the  rumble  of  the  contracting  oesophageal  and 
cervical  muscles  brought  into  play  and  in  about  seven  seconds  the  trickling 
of  the  fluid  entering  the  stomach  through  the  cardiac  orifice.  Delay  or 
absence  of  the  latter  sound  suggests  more  or  less  complete  stenosis  in  the 
course  of  the  oesophagus  or  at  the  cardia. 

Inflation. — The  stomach  may  be  distended  by  means  of  a  stomach- 
tube  and  an  ordinary  rubber  bulb  syringe  or  by  carbon  dioxide  evolved 
within  the  organ  itself.  To  this  end  3  to  5  grammes  of  tartaric  acid  dis- 
solved in  half  a  glass  of  water  are  swallowed  and  this  is  followed  by  an 
equal  amount  of  sodium  bicarbonate  dissolved  in  the  same  quantity  of 
water.  The  stomach  first  distends  at  its  least  resisting  part  and  in  the 
case  of  moderate  enlargement  and  thin  abdominal  walls  its  greater  curva- 
ture and  inferior  border  may  be  made  out  by  inspection  or  auscultatory 
percussion.  The  gas  may  be  expelled  as  it  is  formed  either  at  the  cardia 
or  at  the  pylorus,  and  in  large  stomachs  the  introduction  of  a  sufficient 
quantity  of  air  may  cause  much  discomfort  or  even  pain,  or  the  gas  evolved 
may  be  insufficient.  The  chief  value  of  this  method  lies  in  the  determina- 
tion of  the  size,  outline,  and  position  of  the  stomach.  It  is  of  importance 
in  the  differentiation  between  tumors  of  the  anterior  wall  and  those  sit- 
uated in  the  posterior  wall  or  behind  the  stomach.  It  is  evident  that 
upon  inflation  the  former  will  •  become  more  prominent,  the  latter  less 
obvious.  Inflation  is  of  some  value  also  in  bringing  into  prominence 
obscure  tumors  of  the  pylorus. 

Position  of  Fluids  Ingested  under  Observation. — The  position  of 
the  lower  border  of  the  stomach  is  ascertained  as  closely  as  possible,  the 
patient  standing.  He  is  then  directed  to  swallow  a  glass  of  water  and 
the  resulting  dulness  is  determined  by  percussion.  This  manoeuvre  being 
repeated  two  or  three  times  at  short  intervals,  changes  in  the  level  of  the 
dulness  may  occur,  which  are  indicative  of  the  position  of  the  lower  border 
of  the  stomach.  In  normal  stomachs  of  good  musculature  the  increased 
amount  of  fluid  enlarges  the  area  of  dulness  in  an  upward  direction ;  in 
relaxed  and  dilated  stomachs  the  dulness  sinks  with  the  increasing  weight. 
The  method  is  of  no  great  value  except  in  dilated  stomachs  and  gastroptosis 
in  individuals  with  thinned  abdominal  Avails. 

Transillumination. — The  gastrodiaphane  of  Einhorn  consists  of  a 
flexible  tube  carrying  at  its  top  a  small  electric  light.  The  Kemp  instrument 
has  the  advantage  in  that  its  position  can  be  controlled  from  the  mouth. 
The  patient  drinks  two  or  more  glasses  of  water;  the  tube  is  introduced 
and  the  circuit  completed.  The  light  shows  through  the  abdominal  wall 
in  the  normal  stomach  as  a  triangular  area  having  its  apex  and  focus  of 
intensity  somewhat  to  the  left  of  the  median  line  and  above  the  umbilicus; 
in  gastroptosis  or  dilatation  the  point  of  illumination  is  lower  and  the 
light  more  diffused.  Changes  follow  movements  of  the  bulb.  This  procedure 
shows  the  lowest  limit  of  the  stomach  at  one  point.     There  is  no  certainty 


THE  STOMACH  AND  INTESTINES.  205 

that  the  lamp  does  not  push  the  greater  curvature  into  positions  it  would 
not  otherwise  occupy,  or  that  the  position  of  the  illuminated  area  affords 
positive  data  in  regard  to  the  size  and  shape  of  the  organ. 

Direct  Gastroscopy. — Direct  inspection  of  the  mucous  membrane  of 
the  stomach  through  a  rigid  metal  tube  requires  the  patient  recumbent, 
with  his  head  extended  in  such  a  manner  that  the  trachea  and  oesophagus 
approach  nearly  a  direct  course.  General  anaesthesia  is  recommended  for 
the  best  results.  The  tube  used  is  fitted  with  a  small  electric  light,  mirror, 
and  obturators,  and  in  general  resembles  those  employed  in  the  diagnosis 
of  rectal  and  sigmoid  disorders,  being,  however,  longer  and  slightly  thinner. 
Many  conditions  of  the  stomach  are  readily  recognized  by  direct  inspection. 
Great  care  is  necessary  to  ensure  inspection  of  the  whole  interior,  particu- 
larly if  the  stomach  is  enlarged.  The  cardia  is  first  inspected.  Inflation 
aids  in  bringing  other  parts  into  view.  By  some  manipulation  of  the  upper 
end  of  the  gastroscope  and  simultaneous  palpation  and  manipulation  on  the 
part  of  an  assistant  the  whole  stomach  can  be  gone  over  and  outlined.  The 
readiness  with  which  the  end  of  the  tube  can  be  felt  through  the  abdominal 
wall  is  of  some  service.  The  use  of  the  cesophagoscope  and  gastroscope 
demands  great  technical  skill  and  is  not  without  danger. 

The  Rontgen  Rays. — This  method  of  examination  has  practically 
taken  the  lead  among  other  devices  for  determining  the  form,  size  and 
position  of  the  stomach.  Rontgenoscopy  and  rontgenography  are  employed. 
Serial  rontgenography  yields  the  mast  satisfactory  results  in  the  examination 
of  the  gastro-intestinal  tract.  Plates  sufficiently  large  to  include  the  dome  of 
the  diaphragm  above  and  the  rectum  below  should  be  used.  The  efficient  em- 
ployment of  this  mode  of  examination  requires  not  only  elaborate  and  expen- 
sive apparatus  but  also  great  technical  skill  and  should  only  be  entrusted  to 
those  who  devote  their  whole 'time  to  it  as  a  specialty.  The  practitioner  who 
attempts  to  do  general  work  of  this  kind  invites  failure  both  in  making  the 
rontgenograms  and  in  appreciating  their  significance.  The  patient  should 
take  castor  oil  the  night  preceding  the  exposures  and  no  food  having  been 
eaten,  he  should  swallow  350  to  400  grams  of  buttermilk  with  which  a  suspen- 
sion of  100  grams  of  chemically  pure  barium  sulphate  has  been  stirred.  The 
exposures  follow  immediately  and  after  1,  2,  5,  12,  18,  24,  and  48  hours. 
The  plates  show  the  form,  size  and  position  of  the  stomach,  the  time  required 
by  the  organ  to  empty  itself  and  for  the  passage  through  the  intestines,  also 
the  exact  form-relations  in  various  lesions,  as  nicer,  carcinoma,  cicatrices, 
and  so  forth. 

The  fluoroscopic  screen  is  very  useful,  in  that  the  movements  of  the 
stomach  can  be  watched  and  recorded. 

Tin',  Stomach-Tube. — Various  styles  are  in  use.  They  are  made  of  soft 
red  rubber  with  a  lumen  of  about  .50  to  .7")  cm.,  walls  not  too  thick",  and 
about  To  to  90  fin.  in  length;  near  the  gastric  end  one  or  two  large  Lateral 
openings.  Whether  there  should  be  an  opening  at  the  end  is  a  matter  of 
opinion.  The  upper  end  is  fitted  to  a  glass  funnel  of  a  capacity  of  500  c.c. 
At  the  middle  there  may  be  a  bulb  whieli  serves  for  inflation  or  suction  and 
permits  free  siphonage.  As  the  distance  from  the  incisor  teeth  to  tin-  cardia 
is  on  the  average  40  cm.,  or  slightly  less  than  16  inches,  there  should  be  an 
encircling  mark  at  this  point    It  is  important  to  note  thai  many  of  the  tubes 


206  MEDICAL  DIAGNOSIS. 

supplied  at  the  shops  are  marked  at  a  point  51-60  cm.  from  the  tip,  about 
the  distance  to  the  lowest  point  of  the  greater  curvature.  For  infants  a 
soft  catheter  may  be  used. 

Introducing  the  Tube. — The  sitting  position  is  easiest.  It  is  best  not  to 
elevate  the  chin,  since  stretching  the  neck  seems  to  occlude  the  upper 
oesophagus.  Plates  and  false  teeth  should  be  removed.  Soaking  the  last 
several  inches  of  the  tube  in  hot  water  makes  the  first  contact  of  the  tube 
with  the  pharynx  less  irritating.  Holding  the  tube  in  the  hand,  as  one  would 
a  pen,  with  five  or  six  inches  projecting,  the  examiner  instructs  the  patient 
to  open  his  mouth  moderately  wide,  with  the  tongue  touching  and  against 
the  teeth.  The  tube  is  then  passed  straight  back  to  the  middle  of  the  posterior 
pharyngeal  wall  and  directed  downward.  If  the  patient  can  swallow  at  this 
moment  the  tube  is  usually  engaged  at  once  in  the  upper  oesophagus  and  can 
be  rapidly  pushed  in,  reaching  the  stomach  in  several  seconds,  and  is  securely 
in  place  before  the  first  expulsive  coughing  efforts  begin.    By  ordering  the 


Fig.  83a. — Stomach-tube. — Cohnheim. 

patient  to  breathe  deeply  several  times  one  usually  succeeds  in  quieting  most 
of  the  discomfort  and  can  proceed  with  the  examination.  To  avoid  the  doub- 
ling up  of  the  tube  or  the  unpleasantness  of  the  coughing  or  vomiting  which 
often  ensues,  many  prefer  to  introduce  the  forefinger  of  one  hand  along  the 
side  of  the  mouth  as  a  guide  and  to  pass  the  tube  along  this  guiding  finger. 
Many  attempts  are  often  necessary  to  overcome  the  spasmodic  expulsive 
efforts  of  the  pharynx.  At  times  the  distress  is  such  that  it  is  necessary  to 
forego  the  attempt.  Cocainization  of  the  pharynx  has  been  recommended; 
it  does  not,  however,  seem  to  have  been  very  successful  in  difficult  cases. 

The  contents  of  the  stomach  may  be  obtained  by  voluntary  contractions 
of  the  abdominal  wall,  by  the  vomiting  produced  by  slight  movements  of  the 
tube  or  by  aspiration.  If  aspiration  is  required,  compression  is  made  upon  the 
bulb  and  the  distal  tube  closed  by  grasping  it  between  thumb  and  index  finger 
of  the  other  hand.  The  pressure  on  the  bulb  is  removed  and  the  contents 
are  aspirated  into  the  bulb,  release  the  distal  compression  and  allow  the 
material  to  flow  into  a  basin.  Repeat  the  procedure  as  often  as  required. 
The  stomach  contents  are  usually  removed  one  hour  after  the  test  meal 
when  using  this  style  of  tube. 


THE  STOMACH  AND  INTESTINES.  207 

The  great  value  of  the  stomach-tube  in  gastric  diagnosis  lies  in  the 
ease  with  which  the  stomach  may  be  inflated  and  its  contents  removed. 
Much  time  will  be  saved  by  having  the  patient  take  one  or  other  of  the 
various  test-meals  whenever  the  tube  is  to  be  passed.  After  removal  of  the 
meal  the  patient's  clothes  are  loosened  and  he  is  directed  to  lie  down  with 
the  tube  still  in  position.  Inflation  can  now  be  performed  and  in  conjunction 
with  some  of  the  various  methods  already  mentioned  will  be  found  to  be 
a  very  satisfactory  way  of  estimating  the  size  and  position  of  the  stomach. 

The  stomach  is  inflated  until  the  patient  indicates  the  beginning  of 
discomfort.  The  examiner  then  clamps  the  tube  or  can  ask  the  patient  to 
hold  it  firmly  in  his  teeth,  thus  giving  the  examiner  the  free  use  of  both 
hands.  During  the  inflation  the  examiner  should  carefully  watch  for  the 
area  where  the  stomach  first  manifests  its  presence.  In  a  normal  stomach 
this  will  be  just  below  the  left  costal  margin  and  in  the  epigastrium  between 
the  ensiform  and  navel.  The  stomach  will  stretch  easily  and  its  greater 
curvature  can  be  followed  to  the  umbilicus  before  overdistention  is  com- 
plained of.  The  lesser  curvature 
must  be  outlined  as  well,  either 
by  inspection,  percussion,  or 
auscultatory  percussion,  and 
marked  in  pencil.  Its  position 
should  be  under  the  costal  arch 
as  hi<rh  as  the  sixth  and  seventh 
ribs,  and  just  below  the  ensiform 
cartilage  in  the  midline.  The 
fundus  may  distend  high  up 
toward  the  axilla.  A  distinct 
stomach-shaped  outline  can  usu- 
ally be  obtained.  It  is  only  by 
outlining  both  lesser  and  greater 
curvatures  that  the  difference  between  displaced  and  dilated  stomachs  is 
determined. 

The  great  advantage  of  the  use  of  the  stomach-tube  in  inflating  is  that 
the  process  can  be  repeated  as  often  as  may  be  desired  without  undue  dis- 
comfort or  delay,  since  after  the  first  few  minutes  the  patient  experiences 
little  of  no  uneasiness. 

In  addition  to  the  estimation  of  the  size,  shape,  and  position  of  the 
atomach,  the  Btom;ich-tnl>e  is  used  to  determine  conditions  of  hypersecretion 
and  retention.  To  test  for  hypersecretion  the  stomach-tube  is  passed  in  the 
morning  before  any  fluid  or  food  has  l>cen  ingested,  or  the  stomach  maj  be 
washed  out  and  the  tube  again  passed  after  several  hours'  fasting.  The 
recovery  of  more  than  1<>  to  20  c.c.  suggests  disturbance  of  the  gastric  func 
tions.  In  testing  for  retention  the  examiner  washes  the  stomach  clean,  admin- 
isters certain  solid  articles  of  diet,  and  pnsses  the  tube  to  obtain  samples  of 
the  stomach  contents,  seven  or  eighl  hours  later,  <>r.  according  ;is  marked 
conditions  an  suspected,  twelve,  twenty-four,  or  even  forty-eight  hours 
fitter  the  taking  of  the  meal. 

Contraindications  for  th<  Usi  of  tin  Stomach-tube.-  Those  who  for 
repeated  diagnostic  or  therapeutic  purposes  have  become  accustomed  to  the 


Fig.  836. — Rehfuss  stomach-tube. 


208  MEDICAL  DIAGNOSIS. 

tube  take  it  without  difficulty  and  many  learn  to  introduce  it  themselves. 
Its  first  introduction  is  often  attended  with  great  gagging,  straining,  and 
congestion,  and  is  not  wholly  without  danger  in  elderly  persons  with 
arteriosclerosis,  myocarditis,  and  emphysema  of  high  degree.  It  is  also 
hazardous  and  unjustifiable  in  hemorrhagic  cases,  especially  haemoptysis, 
haematemesis,  or  cases  of  marked  anaemia  with  tarry  stools,  and  in  aneurism 
of  the  aorta,  in  great  debility  from  acute  or  chronic  illness,  and  in  preg- 
nancy. Even  in  the  absence  of  any  of  the  foregoing  conditions  the  retching, 
gagging,  and  distress  of  the  patient  may  be  so  great  that  the  attempt  to  pass 
the  tube  must  be  temporarily  abandoned. 

The  fractional  tube  can  be  used  in  practically  any  condition.  Rehfuss 
claims  he  has  used  it  in  all  forms  of  gastric  disease  with  no  ill  effects. 

(b)  The  Chemical  Examination. — The  further  examination  of  the 
stomach  consists  in  the  administration  of  certain  test-meals  or  substances, 
their  removal  by  means  of  the  stomach-tube  after  a  given  period  of  time, 
and  the  application  of  various  chemical  tests  for  the  digestive  agents  of  the 
gastric  juice. 

Test=Meals. — Several  standard  test-meals  are  in  use. 

Plain  water  is  a  slight  gastric  stimulant  and  brings  out  a  clear  exudate 
from  the  gastric  walls. 

The  Ewald  Test -breakfast. — This  consists  of  35  grammes  of  stale 
bread  or  toast  without  butter  and  200—100  c.c.  of  weak  tea  or  water:  Two 
small  slices  of  toast  without  butter  and  one  cup  of  weak  tea  without  cream 
or  sugar  represent  these  amounts  fairly  well. 

Riegel's  Test-meal. — Two  hundred  c.c.  mutton  broth,  150-200 
grammes  beefsteak,  potato  puree  50  grammes,  one  roll  35-50  grammes  is 
given  to  show  the  reaction  of  the  stomach  to  a  mixed  meal. 

Oatmeal  meals  are  supposed  to  be  free  from  lactic  acid.  Other  meals 
have  in  addition  urea  or'  other  chemicals  in  order  to  determine  the  amount 
of  material  which  has  been  evacuated  from  the  stomach. 

Retention  meals  containing  substances  easily  recognized — such  as 
prunes,  raspberries  or  lycopodium  powder — are  often  given  but  are  not 
necessary  since  the  introduction  of  the  fractional  method  of  gastric  analysis. 

Starch. —  The  effect  of  the  salivary  enzymes  can  be  first  and  most 
simply  ascertained.  The  conversion  of  starch  to  achroodextrin  and  mal- 
tose goes  on  in  the  stomach  until  the  free  acids  of  gastric  secretion  reach 
a  certain  point.  The  well-known  iodine  reaction,  coloring  starch  violet, 
coloring  erythrodextrin,  the  first  product,  mahogany  brown,  and  having 
no  characteristic  color  effect  in  the  final  stages,  achroodextrin  and  maltose, 
allows  us  to  estimate  quickly  and  qualitatively  the  extent  of  salivary  diges- 
tion. Both  the  filtrate  and  residue  contain  reacting  substances,  soluble  and 
insoluble  starch.  Excess  of  unaltered  starch  gives  at  once  with  iodine 
solutions  (Lugol's  solution  .1  Gm.  iodine,  .2  Gm.  potass,  iodide,  200  c.c. 
water)  a  deep  violet  color;  achroodextrin  and  maltose  show  no  color  reac- 
tion, though  the  latter  is  readily  detected  by  Fehling's  solution.  Iodine, 
however,  must  be  added  in  excess,  since  achroodextrin  has  a  greater  affinity 
for  it  than  has  starch,  and  the  violet  starch  reaction  may  only  appear  after 
all  the  achroodextrin  has  been  satisfied.  The  ,same  color  effects  can  be  readily 
seen  under  the  low  power  of  the  microscope. 


THE  STOMACH  AND  INTESTINES.  209 

The  main  relationship  which,  starch  tests,  i.e.,  salivary  digestion,  bear 
to  stomach  digestion  is  that  hyperacid  conditions  of  the  stomach  interfere 
with  its  progress,  and  that  hypo-acid  conditions  may  favor  it. 

The  more  important  tests  in  ordinary  clinical  work  are  those  for  (1) 
acidity;  (2)  presence  of  free  acids;  (3)  presence  of  free  HC1,  lactic  and 
butyric  acids;  (4)  presence  of  HC1  in  combination  (combined  HC1).  Tests 
for  proteid  digestion,  pepsin  and  peptone  reaction,  are  usually  considered 
to  be  unnecessary  when  normal  or  increased  free  HC1  is  found.  Milk- 
curdling  ferment  is  rarely  tested  for.  A  fat-splitting  ferment  in  small 
amounts  has  been  occasionally  demonstrated,  but  is  not  regarded  as  of 
great  practical  importance.  The  qualitative  tests  in  common  use  can  be 
first  considered. 

Qualitative  Tests. — 1.  Test  for  Acidity. — The  products  and  agents 
of  gastric  digestion  are  normally  acid,  this  reaction  being  due  to  free  acids 
— HC1,  lactic  acid,  butyric  acid,  and  their  combinations.  Blue  litmus 
paper  is  reddened  by  their  presence. 

2.  Tests  for  the  Presence  of  Free  Acids. — Congo  red  paper  or 
solution  is  turned  deep  blue  by  free  HC1.  A  less  intense  reaction  is  given 
by  the  organic  acids. 

3.  Tests  for  the  Presence  of  Free  HC1,  Lactic  Acid,  etc. — HCl. 
(a) —  Methyl  Violet  Reaction. — To  a  pale  violet  solution  of  methyl  violet 
(one  drop  concentrated  aqueous  or  alcoholic  solution  in  a  test-tube  of 
water)  add  a  few  drops  of  the  filtrate.  A  distinct  blue  change  takes  place 
if  free  HCl  is  present.     A  control  tube  should  be  on  hand  for  comparison. 

(b)  Tropaolin-  00  Reaction. — Two  or  more  drops  of  fresh  concentrated 
alcoholic  solution  of  tropa^olin  (a  deep  orange-colored  solution)  are  spread 
on  a  porcelain  plate  or  dish.  The  same  amount  of  filtrate  is  added  to  this 
surface  and  the  porcelain  gently  heated.  A  distinct  violet  reaction  turning 
to  blue  takes  place. 

(c)  Phloroglucin-vanUlin  (Gunsburg's)  Reaction. — Two  or  three  drops 
of  the  solution  (phloroglucin  2  Cm.,  vanillin  1  Cm.,  alcohol  30  c.c.)  are 
used  with  the  same  amount  or  more  of  the  filtrate  as  in  the  tropseolin  test 
and  dried  by  gentle  heat.  The  brown  color  of  the  phloroglucin-vanillin  is 
changed  to  a  distinct  carmine  red  if  free  HCl  is  present. 

(d)  I)inicth!jlanii(loa:ohenzol  Reaction. — A  drop  of  a  .5  per  cent,  alco- 
holic solution  of  this  substance  (a  light  red-brown  solution)  added  to  the 
filtrate  or  to  the  residue,  quickly  gives  a  bright  red  color  if  free  HCl  is  pres- 
ent. In  eases  where  but  a  few  drops  of  gastric  contents  have  been  secured 
this  test  can  be  readily  applied  without  waiting  to  filter. 

The  last  two  tests  are  by  far  the  most;  reliable  and  are  generally  con- 
sidered as  absolute  tests  for  the  presence  of  free  IIC1.  Lactic  acid  in  excess 
may  give  Buggestive  results  in  the  methyl  violet  and   tropseoliii  reactions. 

La-ctic  Acid. — Uffelman's  Test. — One  drop  of  a  10  per  cent,  solution 
of  ferric  chloride  is  added  to  20  c.c.  of  a  1  per  cent,  solution  of  carbolic 
acid.  The  resulting  deep  blue  mixture  is  diluted  until  it.  appears  as  a  light 
amethyst.  On  the  addition  of  a  gastric  filtrate  containing  lactic  acid  the 
amethyst  changes  to  distinct  yellow.     Excess  of  free  HCl,  sugars,  or  peptones! 

may  decolorize  the  amethyst,  and  the  yellow  tint  of  many  filtrates  it'  added 
in  excess  gives  suggestive  but  uncertain  results.     A  comparison   with   a 
14 


210  MEDICAL  DIAGNOSIS. 

test  solution  of  lactic  acid  is  always  useful  for  a  beginner.  Far  better 
results  are  obtained  by  shaking  a  portion  of  the  filtrate  with  ether,  which 
extracts  the  lactic  acid,  and  applying  the  test  to  the  evaporated  residue, 
which  may  be  preferably  diluted  with  2  or  3  c.c.  of  water.  Strauss'  modi- 
fication of  this  test  is  also  serviceable.  One  may  dispense  with  the  sep- 
arator if  it  is  not  obtainable.  Five  c.c.  of  ga.stric  juice  are  placed  in  a  test- 
tube;  20  c.c.  of  ether  are  then  added,  the  tube  corked,  thoroughly  shaken 
for  a  few  minutes,  and  allowed  to  settle.  The  overlying  ether  and  extract 
can  now  be  carefully  removed  with  a  pipette  and  mixed  with  5  c.c.  of 
distilled  water.  To  this  mixture  two  drops  of  a  1  in  9  watery  solution  of 
ferric  chloride  are  added  and  the  mixture  is  again  shaken.  The  watery 
layer,  as  it  settles  below,  is  of  an  intense  greenish-yellow  color  if  lactic  acid 
be  present. 

Butyric  Acid. — This  acid  is  usually  only  tested  for  by  its  odor.  This 
and  others  of  the  volatile  fatty  acids,  acetic  and  valerianic,  are  only  looked 
for  in  marked  conditions  of  stagnation  of  the  gastric  contents.  Very 
minute  quantities  of  them  all,  however,  occur  in  various  foodstuffs. 

Combined  II CI. — A  qualitative  test  for  the  proteid  combinations  of 
II  CI  is  not  in  general  use.    The  quantitative  tests  will  be  considered  below. 

Proteid  Digestive  Power. — For  the  qualitative  tests  of  the  power  of 
the  gastric  juice  to  digest  proteid,  one  or  two  simple  devices  have  been  used. 
Fibrin  and  coagulated  albumin  (egg  albumin)  are  the  common  proteids 
used:  the  fibrin  well  washed,  hardened  in  alcohol  and  stained  by  neutral 
carmine,  wTill  digest  in  gastric  juice  containing  free  HC1  and  pepsin,  impart- 
ing a  red  color  to  the  liquid  mixture  as  the  carmine  is  set  free  by  the 
digestion. 

Small  pieces,  or  disks,  2  mm.  in  diameter,  1  mm.  in  thickness,  of  not  too 
firmly  coagulated  egg  albumin  are  placed  in  a  few  c.c.  of  gastric  contents. 
According  to  the  amount'  of  pepsin  and  free  HC1  present  digestion  begins 
more  or  less  rapidly,  and  softening  of  the  edges  of  the  disks  can  be  seen 
in  one  to  two  hours.  Many  hours  are  required  for  the  complete  granulation 
of  either  fibrin  or  albumin.  Gastric  juices  deficient  in  free  HC1  have  less 
and  less  effect  upon  the  proteids  employed.  Some  slight  digestion  goes  on 
even  with  complete  absence  of  free  HC1. 

Neither  of  the  proteid  digestive  tests  is  very  instructive,  and  one 
must  remember  that  the  pepsin  present  in  the  gastric  filtrate  has  been 
already  partly  used  in  the  proteid  digestion  of  the  test-meal.  Sahli's  des- 
moid-proteid  digestive  test  will  be  considered  under  the  absorption  tests. 

Tests  for  Rennin  and  Rennin  Zymogen. — To  10  or  15  c.c.  of  neutral 
milk  add  5  c.c.  of  gastric  filtrate,  and  place  the  mixture  in  a  thermostat  or 
in  any  warm  place.  In  10  to  15  minutes  coagulation  begins.  This  is 
merely  the  familiar  "junket  making."  Free  HC1  is  not  necessary  for  its 
performance. 

Quantitative  Tests. — For  the  differentiation  of  many  of  the  disorders 
of  gastric  secretion  an  estimation  of  the  amount  of  acids  and  acid  combina- 
tions is  often  necessary.  Free  HC1  is  the  only  free  acid  regularly  estimated. 
The  estimation  of  the  total  acidity  of  the  gastric  contents,  which  is  made 
up  of  free  HC1,  traces  perhaps  of  other  acids  (lactic  acid),  and  combina- 
tions of  HC1  and  lactic  acid  (if  present)   with  the  proteids  of  the  admin- 


THE  STOMACH  AND  INTESTINES.  211 

istered  meal,  is  the  next  important  step.     Estimation  of  these   combined 
products  are  also  made. 

Quantitative  Estimation  of  the  Amount  op  Free  HC1. — The  amount 
not  used  in  the  process  of  digestion  at  the  time  of  the  test-meals  removal. 
The  general  principle  of  all  the  tests  for  total  acidity  and  free  acids  is  the 
same,  namely,  to  add  to  the  filtrate  a  standard  alkaline  solution  until  the 
acid  contents  are. neutralized.  To  aid  in  determining  neutralization  vari- 
ous coloring  agents,  some  of  which  have  been  already  described  in  the 
qualitative  tests,  are  added  to  the  gastric  filtrate.  These  coloring  agents 
have  the  peculiarity  of  losing  or  even  changing  their  color  when  the  filtrate 
becomes  neutral  or  faintly  alkaline  in  reaction  from  the  added  alkali.  The 
solution  in  general  use  is  the  "one-tenth  normal"  sodium  hydrate.  This 
one-tenth  normal  solution,  written  X  XaOll,  is  preferred  on  account  of  its 
dilution,  which,  when  dealing  with  such  small  amounts  and  percentage^  as 
are  found  in  the  stomach  contents,  is  very  necessary.  One  c.c.  of  this  X 
XaOH  corresponds  to  or  exactly  neutralizes  .00365  gramme  of  free  HC1. 

Technic. — Dilute  10  c.c.  of  the  gastric  filtrate  with  50  c.c.  of  sterile 
water  and  place  in  a  glass  beaker.  Drop  from  a  graduated  burette  X  XaOH 
until  the  so-called  indicators  or  coloring  agents  show  the  characteristic 
ehanges  indicative  of  complete  neutralization.  The  number  of  c.c.  of  -^ 
XaOH  used,  multiplied  by  the  free  HC1  equivalent  of  1  c.c.  Jl  XaOH 
f. 00365  gramme),  gives  the  amount  of  HC1  in  the  10  c.c.  of  gastric  filtrate, 
and  one  readily  calculates  the-  percentage  amount  therefrom,  normally 
about  .1825  gramme  per  100  c.c. 

At  present  it  is  more  common  to  express  the  results  in  direct  figures  or 
per  cent.,  indicating  merely  how  many  c.c.  of  it  XaOH  are  necessary  to 
neutralize  100  c.c.  of  the  gastric  filtrate  (i.e.,  its  contained  free  HC1),  as, 
for  instance,  if  10  c.c.  of  gastric  filtrate  (containing  free  HC1)  are  neutral- 
ized by  5  c.c.  of  TX  NaOH,  the  percentage  of  free  IIC1  is  said  to  be  50. 

The  most  convenient  indicator  for  free  IIC1  is  dimethylamidoazo- 
benzol.  In  contact  with  free  IICl  in  the  filtrate  g  bright  red  color  is  shown. 
Neutralization  by  TX  XaOH  turns  the  red  color  to  a  turbid  yellow.  The 
beaker  containing  the  filtrate  and  indicator  should  be  well  stirred  or  shaken 
while  adding  the  alkaline  solution  from  the  burette. 

Equally  satisfactory  for  quantitative  estimation  is  the  phloroglucin- 
v.'inillin  test.  Ten  c.c.  of  the  filtrate  are  placed  in  a  beaker,  the  J*  XaOH 
is  added  slowly,  and  after  every  10  to  15  drops  one  takes  n  drop  of  the 
filtrate  and  tests  it  for  free  llfl  on  a  porcelain  plate  with  the  phloroglucin- 
vanillin.  The  aon-appearance  finally  of  any  trace  of  the  carmine-red  color 
indicates  the  complete  neutralization  of  the  free  1101  in  the  filtrate. 

The  Sahli  Test. — The  reagent  is  a  mixture  of  equal  parts  of  a  48  per 
cent,  solution  of  potassium  iodide  and  an  8  per  cent,  solution  of  iodate. 
Free  hydrochloric  acid  added  to  this  reagenl  produces  Free  iodine. 

Technic. — One  o.o.  of  strained  gastric  contents  is  diluted  with  15  c.c. 
of  water,  and  2  c.e.  of  the  reagent  added.  Set  the  mixture  aside  for  sev- 
eral minutes,  then  titrate  with  T^_  sodium  thiosulphate  until  but  a  faint 
yellow  color  remains.  Add  a  \'<-\v  drops  of  a  1  per  cent,  solution  of  soluble 
starch  and  titrate  until  the  blue  color  disappears.  -^ft.  thiosulphate  is  equiv- 
alent to  TX.  alkali.     Therefore  the  number  of  c.c.  used  represents  the  num- 


212  MEDICAL  DIAGNOSIS. 

ber  of  -j—g-  necessary  to  neutralize  the  free  hydrochloric  acid  in  1  c.c.  of 
gastric  contents.    This  is  multiplied  by  10  as  in  former  estimates. 

Estimation  of  Total  Acidity. — The  same  methods  are  used  with 
merely  different  indicators :  either  phenolphthalein  or  rosolic  acid.  Two 
or  three  drops  of  a  1  per  cent,  alcoholic  solution  of  the  former  give  to  the 
gastric  filtrate  a  turbid  appearance.  Upon  the  gradual  addition  of  the 
^  NaOH  there  appears  a  red-purple  color  where  the  drop  strikes,  quickly 
disappearing  at  first  but  becoming  more  and  more  persistent  until  shaking 
the  filtrate  no  longer  causes  the  color  to  disappear.  A  good  rule  to  follow 
in  this  test  is  to  consider  the  reaction  complete  when  the  color  will  remain 
for  40  or  60  seconds. 

Upon  the  addition  of  2  or  3  drops  of  a  concentrated  solution  of  rosolic 
acid  to  10  c.c.  of  the  filtrate  the  color  is  changed  to  light  brown.  Neu- 
tralization is  shown  by  the  appearance  of  a  rosy  red  color. 

Since  the  estimation  of  the  total  acidity  requires  the  greater  amount 
of  alkaline  solution,  it  is  possible  to  make  both  tests  in  one  beaker  con- 
taining 10  c.c.  of  filtrate.  Using  dimethylamidoazobenzol  as  an  indicator 
one  can  find  first  the  amount  of  -^-  NaOH  necessary  to  neutralize  the  free 
HC1  present.  By  adding  phenolphthalein  or  rosolic  acid  to  the  now  light- 
yellow  mixture  the  determination  of  the  total  acidity  can  be  made;  the 
amount  of  ^  NaOH  dropped  in  after  using  the  last  indicator  being  merely 
added  to  the  amount  recorded  in  the  estimation  of  the  free  HC1. 

Frequently  it  is  of  interest  to  estimate  how  much  of  the  secreted  HC1 
has  combined  with  the  proteid  of  the  meal  forming  the  so-called  combined 
HC1.  Many  cases  showing  no  free  HC1  on  tests  will  show  that  there  has 
been  free  HC1  secreted  in  the  stomach  as  evidenced  by  the  existence  of 
its  combined  products. 

The  simplest  tests  require  the  finding  of  the  total  acidity  in  the 
beginning. 

The  total  acidity  represents  free  acid,  acid  combined  with  proteids, 
and  acid  salts  (acid  phosphate). 

Alizarin  as  an  indicator  reacts  acid  to  free  acid  and  acid  salts,  but 
not  to  combinations  of  acids  and  proteids ;  hence  the  difference  between 
two  tests,  the  amount  of  ^  NaOH  used  in  one  with  phenolphthalein  as 
an  indicator,  the  other  with  alizarin,  must  represent  the  acids  in  combina- 
tion. The  reaction  is  complete  when  the  yellow  of  the  indicator  turns  to 
a  distinct  violet. 

To  summarize  these  tests  with  an  example,  the  following  normal 
figures  may  be  used : 

1.  10  c.c.  of  gastric  filtrate  with  phenolphthalein  as  an  indicator  for 
neutralization  require  4  c.c.  -^.  NaOH :  100  c.c.  would  require  40  c.c. 
Free  acids,  acids  in  combination,  acid  salts  =  total  acidity  40. 

2.  10  c.c.  of  gastric  filtrate  with  alizarin  as  indicator  (free  acids,  acid 
salts)  require  3  c.c.  -^  NaOH:  for  neutralization  100  c.c.  would  require 
30  c.c.    Total  acidity  40  —  30  =  10.    Combined  acids  10. 

3.  10  c.c.  of  gastric  juice  with  dimethylamidoazobenzol  as  indicator 
(free  hydrochloric  acid  only)  require  2.5  c.c  -^  NaOH  for  neutralization. 
Free  HC1  therefore  =  25,  in  terms  of  100. 

A  much  more  reliable  method  of  estimating  combined  HC1  is  that  of 


THE  STOMACH  AND  INTESTINES.  213 

Cohnheim  and  Krieger.  Calcium  phosphotungstate  separates  HC1  from 
its  combination  with  albumin  and  albumoses,  the  calcium  uniting"  with  the 
IIC1  forming  neutral  calcium  chloride.  In  the  process  a  reduction  of  the 
total  acidity  takes  place,  corresponding  to  the  amount  of  combined  HC1, 
which  has  been  changed  to  the  neutral  calcium  chloride.  The  difference 
between  titrations  before  and  after  the  calcium  phosphotungstate  reaction 
must  represent  the  amount  of  acid  in  proteid  combination.  The  detail  is 
more  troublesome  than  the  simple  alizarin  process,  but  gives  far  more 
accurate  results  than  can  be  expected  where  two  separate  color  changes  are 
required. 

Four  per  cent,  phosphotungstic  acid  is  neutralized  by  gently  boiling 
with  calcium  carbonate.  Calcium  phosphotungstate  is  formed;  the  solu- 
tion is  filtered,  tested  for  neutrality,  and  can  be  kept  for  any  length  of 
time.  30  c.c.  of  this  calcium  phosphotungstate  are  added  to  10  c.c.  of  gastric 
juice.  A  heavy  precipitate  of  proteid  phosphotungstate  results  while  the 
newly  formed  neutral  calcium  chloride  remains  in  solution.  This  mixture 
is  now  filtered,  the  precipitate  remaining  on  the  filter  paper  being  well 
washed  by  pouring  on  it  distilled  water  (two  or  three  separate  additions  of 
5  or  10  c.c.)  and  adding  the  wash  water  to  the  original  nitrate. 

Using  rosolic  acid  as  an  indicator  the  total  acidity  of  10  c.c.  of  gastric 
juice  is  first  estimated,  then  the  same  test  is  repeated  with  the  material 
obtained  after  the  phosphotungstate  reaction,  usually  about  50  c.c.  of 
clear  fluid.    As  an  illustration : 

1.  Total  acidity  of  10  c.c.  gastric  juice,  rosolic  acid  as  indicator  =  50. 

2.  Total  acidity  of  mixture  (10  c.c.  gastric  juice  -f-  30  c.c.  calcium 
phosphotungstate  4- wash  water),  rosolic  acid  as  indicator  =  35.  50  —  35 
=  15,  difference  due  to  conversion  of  HC1  combined  with  proteids  into 
neutral  calcium  chloride.    Combined  IIC1  therefore  =  15. 

Gastric  juices  in  which  the  free  IIC1  is  absent  are  often  examined 
for  free  HC1  deficiency.  This  is  necessary  if  the  calcium  phosphotung- 
state method  of  estimating  combined  acids  is  used.  The  process  is  simple 
and  similar  to  the  above  tests.  To  10  c.c.  of  filtrate,  dimethylamidoazo- 
benzol  is  added.  With  absence  of  IIC1  there  is  of  course  no  reaction. 
^  II CI  is  now  added  until  a  reaction  for  free  IIC1  takes  place.  If  for 
instance  1  c.c.  ^  ITC1  must  be  added,  the  equation  is  10  c.c.  gastric  filtrate, 
with  dimethylamidoazobenzol  as  indicator,  required  1  c.c.  Jl  IIC1  to  pro- 
duce a  reaction  of  HC1.     In  terms  of  100,  IIC1  deficit  =  10. 

Quantitative  tests  for  lactic  acid  are  not  necessary.  The  chlorides 
as  a  general  rule  are  not  tested.  Since,  however,  their  increase  in  gastric 
carcinoma  has  been  claimed,  a  quantitative  estimation  is  at  times  called 
for.  The  procedure  is  lengthy,  and  for  its  methods  the  reader  is  referred 
to  works  on  chemistry. 

Test  of  Gastric  Absorption.  —  The  absorptive  power  of  the  stomach 
may  he  estimated  by  the  administration,  when  the  organ  is  empty,  of  a 
gelatin  capsule  containing  0.2  6m.  of  potassium!  iodide.  The  saliva  and 
urine  are  tested  at  intervals  of  several  minutes  by  the  addition  of  a  small 
quantity  of  standi  meal  or  a  bit  of  standi  paper  and  IIC1.  A  positive  re- 
action  is  shown  by  the  familiar  blue  color  which  normally  should  appear 


214  MEDICAL  DIAGNOSIS. 

in  the  saliva  in  six  to  fifteen  minutes  and  in  the  urine  in  about  fifteen 
minutes.     This  test  is  of  no  great  value. 

Sahli's  Desmoid  Test. — More  as  a  test  of  peptic  activity  than  of 
gastric  absorption,  this  deserves  mention  and  description.  Recognizing 
that  peptic  digestion  as  shown  in  the  test-tube  represents  by  no  means  the 
conditions  inside  the  stomach,  many  investigators  have  endeavored  to 
invent  some  capsule  which  would  open  and  give  out  its  absorbable  contents 
as  a  result  of  gastric  digestion  alone.  Great  trouble  was  experienced  for 
two  reasons.  First,  osmosis  between  the  contents  of  the  capsule  and  gastric 
juice  took  place  through  the  animal  membranes  (proteid  substances),  and, 
secondly,  many  of  the  substances  used  were  disintegrated  by  the  mus- 
cular action  of  the  stomach.  Sahli's  invention  consisted  in  enclosing  absorb- 
able substances  (iodoform  and  methylene  blue)  in  a  small  piece  of  rubber 
dam,  tying  them  in  with  a  strand  of  raw  catgut.  Osmosis  cannot  take 
place  through  the  rubber;  raw  catgut  can  only  be  dissolved  by  the  gastric 
contents,  resisting  absolutely  the  pancreatic  ferments.  The  appearance  of 
iodine  in  the  saliva  and  methylene  blue  in  the  urine  is  held  to  indicate  that 
the  raw  catgut  has  been  digested  by  the  gastric  juice  and  set  the  contents 
of  the  "pill"  free;  hence  the  main  value  of  the  test  is  the  proof  of  the 
digestion  of  proteid  and  peptic  activity.  The  details  of  the  desmoid  test 
are  as  follows: 

Iodoform  .1  gramme  and  methylene  blue  .05  gramme  are  enclosed  in  a 
square  of  rubber  dam  2X2  cm.  The  rubber  is  stretched  tightly  to  make  a 
small  pill  and  its  loose  ends  tied  with  catgut  which  has  been  previously  soft- 
ened in  water.  All  free  hanging  edges  of  rubber  are  trimmed  off.  The  pill 
properly  formed  should  sink  in  water  and  should  show  no  diffusion  of 
methylene  blue  when  placed  therein.  Well  made  and  tested  in  this  way  a  pill 
given  during  a  full  general  meal,  preferably  at  mid-day,  should  sink  to  the 
bottom  of  the  stomach  and  will  not  be  carried  off  until  the  end  of  digestion. 
In  from  5  to  7  hours  the  first  blue  tingeing  of  the  urine  from  methylene 
blue  takes  place.  Iodine  can  be  determined  in  the  saliva  or  urine  by  shaking 
a  small  quantity  of  the  respective  fluids  with  a  few  c.c.  of  chloroform  and 
adding  pure  colorless  nitric  acid,  a  reddening  of  the  chloroform  being  the 
indicator  of  the  presence  of  iodine. 

Peptic  activity  is  most  conveniently  determined  by  means  of  the  Mett 
glass  tubes  filled  with  coagulated  albumin  and  submitted  to  the  action  of 
the  gastric  juice  for  a  definite  length  of  time.  The  length  of  the  column  of 
albumin  digested  at  each  end  of  the  tube  is  determined  accurately  with  a 
low  power  microscope  and  measured  with  a  millimeter  scale.  The  figure 
adopted  is  the  mean  of  both  ends. 

Since  the  digestibility  of  egg  albumin  varies  greatly  the  method  of 
Nirenstein  and  Schiff  is  recommended  (Hawk).  The  tubes  are  prepared  by 
Christiansen's  method  as  follows:  The  whites  of  several  eggs  are  strained 
through  cheesecloth.  Glass  tubing  8-10  inches  in  length  and  1-2  mm.  in 
diameter  is  sucked  full  of  egg  albumin  and  laid  in  a  horizontal  position. 
A  large  evaporating  dish  is  filled  with  water  which  is  heated  to  the  boiling 
point  and  allowed  to  cool  to  exactly  85°  C.  The  tubes  are  placed  in  the 
water  at  85°  C.  and  allowed  to  remain  there  until  cool.  These  tubes  con- 
tain soft  boiled  material  which  is  more  readilv  digested  than  if  hard  boiled. 


THE  STOMACH  AND  INTESTINES.  215 

The  ends  are  sealed  by  dipping  in  melted  paraffin  and  when  ready  for  use 
marked  with  a  file  and  broken  into  pieces  of  appropriate  lengths — three- 
fourths  inch.  Christiansen  gives  the  following  method  for  controlling  their 
digestibility:  1  c.c.  of  gastric  juice  is  put  into  a  small  Erlenmeyer  Mask 
and  15  c.c.  of  J^  HC1  added.  The  flask  is  stoppered  and  placed  in  an 
incubator  for  twenty-four  hours  at  37°  C.  At  the  end  of  that  time  the 
tubes  are  removed,  and  the  amount  of  digestion  calculated  at  both  ends  of 
the  tube,  and  the  mean  of  the  tube  readings  adopted. 

The  peptic  power  is  expressed  by  the  square  of  the  number  of  mm. 
digested.  A  reading  of  2  mm.  gives  a  digesting  power  of  4,  or  in  the  undi- 
luted juice  4  times  16  or  64. 

Tests  of  the  Motor  Power  of  the  Stomach. — Lavage. — A  satisfactory 
test  for  gastric  motility  consists  in  the  administration  of  a  Riegel  test-meal 
and  the  washing  out  of  the  stomach  at  the  end  of  seven  hours,  when  under 
normal  conditions  the  organ  will  be  found  to  have  emptied  itself.  After  an 
Ewald  test-meal  traces  of  food  should  have  disappeared  at  the  end  of  two 
hours.  No  remnants  of  an  ordinary  supper  should  be  found  upon  washing 
out  the  stomach  the  following  morning  after  rising  at  the  usual  hour.  In 
atonic  conditions  and  dilatation  remnants  of  partially  digested  food  may  be 
washed  out  not  only  at  the  end  of  these  periods  but  in  extreme  cases  even  at 
the  end  of  two  or  three  days. 

The  Salol  Test. — Less  reliable  is  the  administration  of  one  gramme 
of  salol  in  gelatin  capsules  directly  after  an  ordinary  meal.  The  urine  is 
voided  at  subsequent  intervals  of  half  an  hour,  one,  two,  three,  and  twenty- 
seven  hours,  and  the  respective  discharges  preserved  for  examination  in 
separate  vials.  Each  portion  is  then  separately  tested  for  the  presence  of 
salicyluric  acid  by  the  addition  of  a  small  quantity  of  a  solution  of  ferric 
chloride,  which  develops  in  the  presence  of  the  acid  a  violet  color.  The 
presence  of  salicyluric  acid  in  the  urine  is  the  sign  of  the  decomposition 
of  the  salol  into  phenol  and  salicylic  acid,  and,  as  this  takes  place  only 
in  an  alkaline  medium,  it  is  the  indication  that  the  salol  has  passed  from  the 
stomach  into  the  intestine,  which  with  normal  gastric  motility  takes  place 
in  about  one  hour.  A  retarded  reaction  indicates  impairment  of  motility, 
a  delay  of  twenty-four  hours  is  suggestive  of  pyloric  obstruction.  This  test 
is  not  accurate,  as  it  is  impossible  to  determine  in  different  individuals  the 
relative  time  consumed  by  the  chemical  changes  in  the  intestine  and  the 
elimination  by  the  kidneys.  Moreover,  the  salol  may  go  out  of  the  stomach 
not  with  the  first  portion  of  the  food  but  with  the  last.  Normally  all  of 
the  salicyluric  acid  sin  old  have  been  eliminated  within  twenty-seven  hours. 

Occult  blood  may  be  demonstrated  by  the  tests  described  elsewhere  in 
the  examination  for  blood.  Wagner's  method  is  probably  the  most  satis- 
factory.    Smears  are  made  of  the  gastric  material  to  which  is  added  in 

equal  parts  a  concentrated  solution  of  benzidine  in   glacial   acetic  acid  and 

peroxide  of  hydrogen  solution.  II"  blood  is  presenl  a  bluish-green  color 
will  soon  appear. 

(c)  Microscopical  Examination  of  Gastric  Contents.-  With  the  ordi- 
nary Ewald  test-meal  little  is  to  be  learned  by  microscopical  examination. 
Starch  granules,  a  few  epithelial  cells,  and  bacteria  are  usually  seen.  If 
there  has  been  much  trouble  in  passing  the  tube  a  few  blood-cells  may  be 


216  MEDICAL  DIAGNOSIS. 

found.  With  a  mixed  meal  or  in  vomited  material  starch,  potato  starch, 
fat  droplets,  and  meat  fibres  are  readily  recognized.  Many  and  larger 
bacteria  are  seen,  a  few  leucocytes  are  commonly  met  with,  and  in  sedi- 
ments deposited  after  standing,  many  large  granular  mononuclear  cells. 
In  cases  of  acute  gastritis  considerable  blood  and  pus  may  be  found  among 
the  stringy,  transparent  strands  of  mucus.  In  gastric  ulcer,  blood  in  the 
test-meal  or  vomitus  is  common.  It  may  be  recognizable  if  the  hemorrhage 
has  been  recent.  The  hyperacid  condition  of  the  gastric  juice  in  these 
cases,  however,  destroys  the  blood-cells  rapidly  and  chemical  tests  for  the 
blood  are  necessary.  Tissue  cells  from  the  ulcerating  area  are  often  found. 
In  gastric  cancer  with  lessened  acidity  blood-cells  are  less,  quickly  destroyed, 
but  as  a  general  rule  the  digestive  juices  rapidly  alter  the  separate  cells. 
Small  clots  which  have  partially  resisted  the  gastric  juice  form  the  sediment 
in  the  characteristic  "coffee-grounds"  vomitusi  of  cancer  of  the  stomach. 
Occasionally  small  masses  showing  distinct  adenocarcinomatous  arrange- 
ment may  be  found  and  are  conclusive  proof  of  the  existence  of  cancer. 
Small  masses  of  tumor  visible  macroscopically  are  occasionally  seen  in  the 
vomit  or  washings  from  a  carcinomatous  stomach. 

Of  the  bacilli  present  a  majority  are  small,  more  or  less  motile,  prob- 
ably introduced  with  food.  A  few  extra  large  organisms  of  the  hay  bacillus 
group  are  always  to  be  found.  One  should  be  careful  not  to  consider  these 
large  regular  organisms  as  the  form  described  by  Oppler  and  Boas.  The 
latter  are  large,  irregular  club-shaped  and  vacuolated  bacilli,  possibly  the 
degenerate  forms  of  the  so-called  gas  bacillus,  or  of  a  special  lactic  acid 
forming  bacillus.  They  are  most  commonly  found  when  lactic  acid  is  pres- 
ent, and  under  this  condition  have  been  considered  as  suggestive  of  cancer. 

Einhorn's  Bead-test  of  Digestive  Activity. — Six  small  glass  beads 
are  connected  with  a  silk  thread;  to  each  bead  is  tied  some  particular 
sort  of  food.  Raw  catgut  and  a  soft  long-bone  of  a  pickled  herring  are  the 
two  substances  used  to  test  gastric  digestion ;  raw  meat,  raw  thymus  gland, 
mutton  fat,  and  a  cube  of  cooked  potato  test  the  intestinal  digestive  power. 
The  beads  and  thread  can  be  placed  together  in  a  gelatin  capsule  and  swal- 
lowed. Normally  the  beads  should  appear  in  the  stool  in  one  or  two 
days;  their  elimination  earlier  than  this  indicates  accelerated  motility  of 
the  intestine ;  their  appearance  in  the  stool  later  than  two  days  after 
administration  is  held  to  indicate  retardation  of  the  fecal  excretion.  All 
the  beads  should  be  empty,  though  traces  of  fat,  thymus,  and  fish-bone 
may  be  left  undigested.  Excretion  of  the  catgut  and  fish-bone  undigested 
would  indicate  impaired  gastric  digestion.  Excretion  of  undigested  meat, 
thymus,  or  fat  indicates  deficient  intestinal  digestion.  The  silk  thread  is 
of  course  merely  to  facilitate  the  finding  of  the  beads. 

The  Fractional  Method  of  Gastric  Analysis.1 

The  Fractional  Tube. —  The  older  methods  of  gastric  analysis  were 
repeatedly  found  so  inaccurate  in  Hawk's  Laboratory  that  a  new  procedure 
was  developed  by  Rehfuss — the  so-called  "Fractional  Method."  The  accom- 
panying illustration  shows  the  impossibility  of  interpreting  gastric  work 

1  Contributed  by  Martin  E.  Rehfuss,  M.D.,  collaborator. 


Plate  II A. 


K,  free  nuclei;  Sp,  spirals;  Sch,  mucus;  //,  yeast-cells; 
B,  epithelium;  AE,  alveolar  epithelium.—  Cohaheim. 


E,  epithelium;  L,  leucocytes;  RB,    red  blood- 
cells;   F,   fat-cells.      Colinlieilii. 


tarch-cell  ;  ET,  yeast-cells;  8a,  saroine; 
M,  muscle  di.n    .  /•'.  Fat-balls  :<n<l  drop! 
potato-starch  cells.     <  iohnheim. 


r7,  yeast-cells;  Jf,  muscle-fibres;  £,  leucocyte   with 
~\w  unken  Duclei;    B,  Oppler-Boas  bacilli;   St,  starch- 
cell   .  /',  Fat;  B,  epithelium;  K,  potato  starch-ceils  with 
•  lis,     <  'ohnheim. 


THE  STOMACH  AND  INTESTINES. 


217 


from  a  single  examination,  the  one-hour  investigation  being  susceptible  to 
the  various  interpretations  shown  in  the  drawing,  each  of  them  being  of 
different  significance. 

A  special  tube  has  been  devised,  the  ' '  Rehfuss  Stomach  Tube, ' '  which 
can  be  left  in  the  stomach  for  long  intervals  without  inconvenience  to  the 
patient.  Rehfuss  has  left  the  tube  in  the  stomach  for  days  without  bad 
effect.  The  tube  is  of  small  bore  (No.  10-12  French)  100  cm.  in  length  to 
permit  both  gastric  and  duodenal  work,  glass  moulded  and  fitted  with  a 
metal  tip  of  sufficient  weight  to  gravitate  to  the  bottom  of  the  stomach. 
The  slots  are  the  same  size  as  the  tubing  in  order  that  anything  which  passes 
through  the  slot  will  pass  through  the  tube.  An  aspirating  syringe 
makes  the  apparatus  complete.     The  tube  is  introduced  into  the  stomach 


50-CALLEO    LARVAE   HYPER-ACIDITY 


ACHYLIAS   £»US-ACIO)TIE3 
DELAVED  DIGESTION 
SUB-ACIDITIES 
ORDINARY  COURSE  DIGESTION 
Fig.  84. — Possibilities  in  the  evolution  of  the  secretory  curve  of  digestion. 

by  swallowing  and  not  by  propulsion  which  is  used  in  introducing  the  older 
type  of  tube.  With  this  instrument  it  is  possible  to  follow  every  phase  in 
gastric  digestion.  Rehfuss  has  studied  the  changes  occurring  after  the 
ingestion  of  all  varieties  of  food. 

Method  of  Introduction. — The  tip  of  the  lube  is  Lubricated  with  vase- 
line, glycerin,  or  lubricating  jelly.  False  teeth  or  other  movable  objects 
are  removed  from  the  month.  The  physician  grasps  the  tip  between  the 
thumb  and  forefinger  and  passes  it  along  the  hack  of  the  ton-ue  until  h 
engages  in  the  pharynx.  The  patienl  is  encouraged  to  swallow  this  carries 
the  tube  into  the  Btomach.  Any  difficulty  is  overcome  by  deep  breathing  or 
by  the  drinking  of  water.  Many  patients  are  able  to  swallow  the  tube 
without  any  help  whatsoever.  A  supersensitive  pharynx  may  be  painted 
or  sprayed  with  a  2  or  4  per  cent,  .solution  of  cocaine  hydrochloride.  <  >ne  ma\ 
make  several  applications  to  the  pool  of  the  tongue  and  to  the  epiglottis. 
This  is  exceptional  and  not  a  routine  procedure. 


218 


MEDICAL  DIAGNOSIS. 


There  are  certain  points  which  are  of  practical  value.  The  tube  gradu- 
ally enters  the  stomach.  That  it  is  still  in  the  oesophagus  is  shown  by  the  fol- 
lowing points :  (1)  aspiration  removes  a  small  sample  of  saliva  or  oesophageal 
mucus,  or  (2)  it  discloses  a  block,  no  material  being  aspirated  owing  to  the 
closure  of  the  slots  by  the  oesophageal  walls;  (3)  injection  of  fluid  occurs 
readily,  but  cannot  be  reaspirated  because  it  has  entered  the  stomach. 

When  the  tube  enters  the  "air  chamber"  it  is  recognized  by  the  fact 
that:  (1)  aspiration  brings  back  air,  (2)  injection  is  easily  performed  but 
no  liquid  can  be  reaspirated. 

The  gastric  secretion  is  obtained  and  readily  recognized  when  the  tube 
enters  the  fundus.  Inability  to  recover  material  is  due  to  one  or  more 
of  the  following  factors:  (1)  an  unclean  tube.  It  should  always  be  tested 
before  using;  (2)  the  tube  is  in  the  oesophagus,  cardia  or  air  chamber;  (3) 
the  tube  is  blocked  by  material  too  coarse  to  pass  through  it ;  (4)  too  much 

tubing  has  been  passed  and  the  tip  may 
be  in  the  pylorus ;  (5)  occasionally  hyper- 
active peristalsis  may  tie  a  knot  in  the 
tube. 

The  end  point  of  gastric  digestion  or 
the  exact  point  of  gastric  evacuation  is 
determined  by  means  of  the  following 
points:  (1)  No  more  food  can  be  aspi- 
rated, (2)  by  a  change  in  the  appearance 
of  the  samples  and  the  addition  of  a  little 
pyloric  mucus,  (3)  the  injection  of  water 
into  the  stomach  and  itsreaspiration  dem- 
onstrates the  absence  of  all  food,  (4) 
when  water  is  injected  auscultation  will 
reveal  a  hissing  instead  of  a  gurgling 
sound.  Ordinarily  about  55-60  cm.  of 
tubing  is  passed,  depending  upon  the 
position  and  size  of  the  stomach. 

Gastric  Lavage. — Is  performed  read- 
ily with  this  tube.  The  correct  time 
for  lavage  with  the  fractional  tube  is 
when  the  stomach  is  empty.  Various  lavage  liquids  can  be  introduced  into 
the  stomach  and  reaspirated ;  if  normal  salt  solution  is  used  the  material  re- 
moved can  be  centrifugalized,  stained  and  cytological  studies  made.  This 
often  reveals  interesting  data  in  gastric  conditions. 

Inflation  and  Auscultation. — Can  be  performed.  The  stomach  is  easily 
and  completely  inflated  with  a  bulb,  and  the  outlines  of  the  organ  deter- 
mined by  palpation  or  percussion.  It  is  interesting  to  combine  auscultatory 
study  with  inflation.  When  the  viscus  is  full  of  material — especially  hyper- 
secretion or  liquid — a  number  of  small  gurgling  rales  are  heard;  as  the 
organ  is  evacuated,  the  rales  become  discontinuous  and  "sticky."  Finally, 
when  the  organ  is  completely  evacuated,  after  a  few  initial  sticky  rales,  the 
rush  of  air  is  distinctly  heard  and  fades  out  as  the  stethoscope  is  placed 
over  areas  other  than  that  of  the  stomach. 

The  Syphon  Method    (Fig.   86). — The  end  of  the  tube  is  allowed  to 


Fig.  85. — Stomach  tube  in  position. 


THE  STOMACH  AND  INTESTINES. 


219 


drain  over  the  edge  of  the  bed  and  the  gastric  specimens  accumulated  in 
tubes.     Hypersecretion  can  be  studied  in  this  way  and  affords  considerable 


Fig.  86. — Syphon  method  of  obtaining  gastric  secretion. 


information  of  value.    Furthermore,  the  determination  of  occult  blood  obvi- 
ates the  possibility  of  trauma  in  the  collection  of  the  sample. 

Medicaments,  such  as  silver,  iodides  and  various  disinfect- 
ants, can  be  made  and  controlled  with  the  fractional  tube.  The 
tube  may  be  introduced  into  the  stomach,  or  the  duodenum,  or 
both,  and  fluids  with  or  without  medication  administered  by  the 
drop  method  similar  to  the  Murphy  drip  used  in  intestinal 
work.  {b) 

Gastric  Intubation. — The  direct  study  of  gastric  work  has 
undergone  considerable  alteration.     It  is  possible  to  study  every 
phase  of  gastric  digestion  and  to  demonstrate  the  alterations  in 
disease.     A  single  examination  at  a  definite  time  after  the  ad- 
ministration  of  a  test  meal  was  formerly  thought  sufficient  to 
determine  gastric  efficiency.     The  introduction  of  the  fractional 
gastric  tube  1ms  totally  altered  this  conception.     It  is  realized 
that  there  are  two  periods  of  gastric  activity,  one  the  digestive 
period  in  response  to  the  stimulus  of  ingested  food  (Fig.  87), 
the  other  the  interdigestive  or  rest  period  during  which  the 
gastric  walls  are  more  or  Less  approximated  by  peristole 
while  peristalsis  practi- 
cally  ceases.     Tonal   or 
hunger    contractions    at 
intervals  take  theirplaee. 
I  lastric  digesl  ion  consists 
of  an  evuliit  ion  of  changes 
and    a   single   examina- 
tion  of  tlie  meal   gives 
no  evidence  of  what  pre- 
cedes   or     follows    that 
point  in  digestion.    This 
lias  been  determined  by  studies  made  upon  a  large  number  of  normal  indi- 
viduals.   These  changes  are  altered  in  disease  nut  only  in  the  character  of 


88a. 


Medicaments    applied    to   stomach. 
/.,   Murphy  drip. 


a,    Rehfuss    tube; 


220 


MEDICAL  DIAGNOSIS. 


their  evolution  but  by  the  addition  of  products  characteristic  of  disease,  viz., 
mucus,  pus,  blood,  bacterial  products  and  the  specific  products'  of  the 
diseased  process.  Gastric  intubation  will  give  not  alone  the  type  of  gastric 
digestion  but  also  the  evidence  of  disease — made  possible  by  a  study  of  the 
products  enumerated  above. 

The  residuum  is  the  material  obtained  from  the  stomach  during  the 
interdigestive  (rest)  period.  It  is  usually  obtained  in  the  morning.  It 
normally  averages  30-50  c.c,  is  thin,  opalescent,  contains  bile  in  over  one- 
half  the  cases,  has  an  average  total  acidity  of  30,  and  an  average  free 
acidity  of  18-20.  It  may  contain  gastric  mucus  equally  distributed  through- 
out the  specimen  as  differentiated  from  swallowed  mucus,  which  is  aerated 
and  floats  on  the  specimen.  It  should  contain  no  pus,  blood  or  macro- 
scopic food.  The  residuum  enables;  one  to  differentiate  between  swallowed 
material  and  exudation  from  the  gastric  wall.  It  demonstrates  the  presence 
of  retention  which  may  be  intermittent  in  spasm,  or  permanent  in  gastric 
disease — intragastric  from  indurated  ulcer,  neoplasm  near  the  pylorus,  a 
hypertrophic  pylorus,  or  weakness  of  the  gastric  wall  as  found  in  the  atonies 


.DIGESTIVE  PEMO 

D 

INTER- 
DIGESTIVE. P. 

I 

TES1 

OVER  THIS    PERIOD 

it 
o 

• 
1 

<^r~~^^ 

*■•:  X. 

3    "J 

Z 

ACCUMULATION-  PATHOLOGICAL 
PROOUCTS 

ir 

•  • '  %, 

^ID> 

\1D 

IP 

m 

GASTRIC  -'WORK 

.  .*<*%%. 

o 

rooo 

FOOO    RE5IOUE 

NO 
FOOD 

FOOD 

NEW  MEAL 

LEFT 
Fig.  87. — Digestive  and  interdigestive  periods. 

and  myasthenias  in  the  various  forms  of  dilatation,  or  extragastric  from 
adhesions  and  tumors  of  the  gall-bladder  and  pancreas,  etc. 

Fractional  Analysis.— Remove  by  gentle  aspiration  5-10  c.c.  of  gastric 
material  after  the  administration  of  the  test  meal.  Repeat  at  fifteen  minute 
intervals  until  the  end  point  in  gastric  digestion  has  been  reached.  The 
interval  may  be  lengthened  to  twenty  or  thirty  minutes  if  digestion  is 
delayed.  Collect  the  specimens  in  a  series  of  labelled  tubes  and  examine 
each  specimen  separately.  The  material  is  strained  through  cheesecloth 
and  the  filtrate  examined  chemically  by  the  same  methods  used  when  the 
single  one-hour  gastric  specimen  is  obtained,  excepting  1  c.c.  of  filtrate  is 
used  instead  of  10  and  -^NaOH  is  used  instead  of  -£L  NaOH.  In  calculat- 
ing the  percentage  this  fact  must  be  kept  in  mind,  and  the  reading  multi- 
plied by  10  to  determine  the  number  of  c.c.  of  ^  NaOH  necessary  to 
neutralize  100  c.c.  of  gastric  material. 

Duodenal  Intubation.  —  This  method  is  important  and  is  rapidly 
becoming  a  routine  procedure  for  the  study  of  the  bile  and  the  pancreatic 
secretion.  The  R  eh  fuss  tube  or  the  duodenal  tubes  of  Einhorn  and  Jutte 
are  employed,  about  75  or  80  cm.  of  the  tube  being  passed  as  for  gastric 


TIME 


'A 


/hr.  l/2  2hr.  2'/Z 


NORMAL  CURVES 

Fia.  88. 


TIME 


■ACHYLIA     AND    ANACIDITY 

DELAYED    DIGESTION 

SUBACIOITY 
-  TARDIVE    HYPERACIDITY 

HYPERACIDITY 

PLATEAU  CURVE  SEEN  IN  STENOSIS 
■LARVAL     HYPERACIDITY 


3/tr. 


PATHOLOGICAL  CURVES 

Fig.  89. 


THE  STOMACH  AND  INTESTINES.  221 

analysis.  Clear  broth  or  bouillon  is  given.  The  patient  is  turned  on  his 
right  side  with  the  pelvis  rotated,  the  left  leg  swung  over  the  right  and 
maintained  in  this  position.  The  pelvis  may  be  elevated  by  placing  the 
pillow  under  the  hips.  Gentle  aspiration  is  performed  in  three-quarters  of 
an  hour  and  repeated  at  fifteen  minute  intervals  until  bile  is  obtained. 
This  is  readily  recognized  by  its  color,  general  appearance  and  viscidity. 
When  bile  is  secured  gentle  aspiration  may  be  used  to  secure  other  speci- 
mens. The  syphon  method,  however,  is  the  most  satisfactory.  The  same 
chemical,  microscopical  and  bacteriological  examinations  are  made  as  in  the 
examination  of  other  body  fluids. 

Gastro=Duodenal  Intubation. — Castro-duodenal  intubation  for  simul- 
taneous examinations  of  the  stomach  and  duodenum  can  be  performed  by 
the  Rehfuss  double  gastro-duodenal  tube  or  by  the  Palef.ski  tube,  or  more 
easily  by  primary  duodenal  intubation,  followed  by  gastric  intubation  after 
bile  has  been  secured  from  the  duodenal  tube.  Samples  can  be  secured  in 
series  as  already  described. 

The  gastric  curve  in  health  is  shown  in  the  accompanying  illustration. 
There  is  no  curve  which  can  be  considered  as  ideal,  inasmuch  as  Rehfuss' 
studies  of  normal  individuals  showed  that  they  reacted  differently  to  the 
saine  stimulus,  but  in  general  all  follow  the  same  trend.  The  response  is 
exaggerated  in  one — the  hypersecretory  type — and  in  another  somewhat 
sluggish — the  hyposecretory  type.  The  evacuation  time  is  generally  between 
two  and  two  and  one-half  hours  with  an  Ewald  meal.  Premature  evacua- 
tion occurs  in  achylia.  gastric  and  the  subacidities,  in  certain  forms  of 
scirrhous  carcinoma,  in  a  small  proportion  of  duodenal  ulcers,  and  of 
nervous  hyperperistalsis.  Delayed  evacuation  is  seen  in  a  multitude  of 
conditions  with  a  slight  delay  in  the  atonies,  and  in  some  forms  of  ulcer 
pronounced  delays  are  seen  in  pyloric  obstruction,  in  indurated  ulcer  or 
neoplasm  at  the  pylorus. 

The  secretory  variations  are  many  (Pigs.  88  and  89).  We  may  have  an 
absolutely  flat  curve  in  achylia  (without  enzymes)  and  anacidity,  or  low 
curves  in  the  subacidities  and  the  delayed  responses.  We  may  have  prema- 
ture or  larval  hyperacidity  or  the  long  delayed  hyperacidity  so  frequently 
;iss-c>eiated  with  post-digestive  hypersecretion.  Again,  we  may  have  a  clean 
digestion  associated  with  secretory  variations,  or  these  variations  may  be 
associated  with  all  the  phenomena  of  intragastric  lesions,  pus.  blood,  mucus, 
bacteria — neoplasm,  syphilis,  tuberculosis,  and  infective  gastritis.  Lesions 
in  the  gall-bladder,  appendix  and  other  parts  of  the  abdomen  may  alter 
the  secretion  through  the  vagus.  Cardiac  incompensation  and  portal  hyper- 
tension incident  to  hepatic  cirrhosis  may  induce  secondary  gastritis  with 
mucus  and  secretory  alterations,  etc. 

EXAMINATION  OF  THE  INTESTINES  AND  F/ECES. 

Only  the  lower  bowel  is  accessible  for  direct  examination  of  its  interior. 

Inspection  with  the  aid  of  proctoscopes,  digital  examination  of  the  rectum. 
and  inflation  of  the  colonic  area  enable  us  to  investigate  at  least  a  part  of 
the  large  bowel  directly.  The  remainder  as  well  as  the  small  intestine 
can  only  be   reckoned  with  through  the   abdominal  wall  by   inspection, 


£ 


222  MEDICAL  DIAGNOSIS. 

palpation,  percussion,  auscultation,  and  radioscopy.  On  the  other  hand,  a 
careful  examination  of  the  faeces  will  tell  us  much  as  to  function  of  the 
intestines  and  as  to  the  presence  of  abnormal  conditions. 

Inspection  as  applied  to  the  examination  of  the  intestines  may  be, 
as  we  have  said,  direct  when  we  are  dealing  with  the  large  bowel;  the 
proctoscope  and  the  rectal  tubes  allowing  inspection  of  the  mucous  mem- 
brane practically  to  the  splenic  flexure  of  the  colon.  The  tubes  or  specula 
come  in  varying  sizes,  usually  four  in  a  set,  ranging  from  4  to  14  inches 
(14  to  35  cm.)  in  length  and  from  1  inch  diameter  in  the  short  speculum 
to  \  inch  diameter  in  the  longer.  They  are  provided  with  obturators. 
Their  use  is  associated  with  considerable  pain,  though  with  persistence 
and  gentleness  most  patients  can  go  through  the  performance  without 
an  anaesthetic.  Warming  and  oiling  the  instruments  thoroughly  will 
overcome  some  of  the  difficulties.  After  the  sphincter  muscle  of  the  anus 
has  been  stretched  and  dilated  the  discomfort  lessens.  Either  the  knee- 
chest  or  the  recumbent  posture  with  the  knees  elevated  may  be  used. 
Too  much  elevation  of  the  lower  part  of  the  body  will  naturally  by  gravity 

send  the  bowel  away 
from  the  examiner.  The 
electric  headlight  with 
reflector  facilitates  ex- 
amination. Very  little 
trouble  is  experienced  in 
straightening  out  the 
sigmoid  flexure,  nor  do 
the  valves  of  the  rectum 
Fig.  90.— Rectoscope.  interfere  with  the  prog- 

ress of  the  speculum. 
It  is   common  to  find  that  the  bowel  dilates  perceptibly  with   air  when 
the  speculum  is  in  place,  thus  materially  aiding  the  examination. 

In  the  more  modern  rectoscopes  and  sigmoidoscopes  the  distal  end  is 
so  arranged  that  air  can  be  forced  into  the  bowel  in  front  of  the  advancing 
tube.  A  glass  shield  near  the  distal  end  allows  the  observer  to  look  into 
the  bowel  and  at  the  same  time  keeps  in  the  injected  air  which  balloons 
the  bowel  for  several  inches.  A  small  electric  light  arranged  in  front  of  the 
tube  gives  a  clear  view  of  the  mucous  membrane. 

Inspection  with  the  proctoscope  or  rectoscope  may  show  us  first 
the  presence  of  scybala,  beyond  reach  of  the  palpating  finger,  revealing 
themselves  often  as  hard,  adherent,  though  detachable,  masses  of  vary- 
ing size,  dark  in  color,  or  gray  if  covered  by  mucus,  and  usually  easily 
indented  or  broken  away  with  a  probe,  and  readily  differentiated  from 
polypoid  and  other  growths;  second,  ulcerating  and  bleeding  points, 
dilated  venules,  fistulous  communications,  thickening  and  reddening  of 
the  mucous  membrane  of  the  bowel;  general  reddening  of  the  whole  sur- 
face in  colitis,  showing  mucus,  glairy  or  dense  and  white  if  the  condition 
of  mucous  colitis  is  present,  and  often  in  large  amounts;  third,  polypoid 
growths,  malignant  growths  in  the  form  of  local  thickening,  strictures, 
foreign  bodies,  ulcerating  tumor  masses;  fourth,  obstructions  outside  the 
bowel,  tumors  of  uterus,  ovary,  etc.,  preventing  insertion  of  the  examining 


THE  STOMACH  AND  INTESTINES.  223 

tubes.  It  is  usually  considered  permissible  and  advisable  to  remove 
small  particles  of  suspicious  growths  for  microscopical  examination. 

Examination  of  the  bowel  by  means  of  bougies  may  at  times  help  in 
diagnosing  a  stricture,  particularly  if  the  feeling  of  distinct  resistance  and 
the  sensation  of  passing  an  obstruction  can  be  appreciated  repeatedly  at 
the  same  point  both  during  the  introduction  and  withdrawal  of  the  sound. 

Palpation  as  a  means  of  examination  in  regard  to  the  intestine  has 
but  limited  direct  application,  namely,  the  examination  of  the  rectum 
by  the  finger,  or  if  the  sphincter  can  be  dilated  by  two  fingers  or  the  whole 
hand.  Examination  is  always  facilitated  by  a  previous  good  clearing  out 
of  the  lower  bowel.  The  forefinger  of  either  hand  may  be  used  and  various 
positions  employed.  The  examiner,  however,  reaches  a  higher  point  in 
the  bowel  if  the  patient  lies  on  his  side  with  his  knees  drawn  up  to  a  mod- 
erate extent.  In  this  posture  more  freedom  is  given  the  introduced  finger, 
and  the  rotation  of  the  hand  and  finger  in  examining  the  sides  and  front 
of  the  rectum  much  aided.    The  knee-chest  position  is  also  convenient. 

To  avoid  the  unpleasant  fecal  odor  it  is  advised  to  fill  the  space  be- 
tween one's  nail  and  finger  with  a  little  moist  soap  and  to  follow  this  by  a 
free  greasing  of  the  finger  with  oil  or  vaseline.    A  finger  cot  can  be  used. 

After  inspecting  the  anus  and  neighborhood  for  fissures,  fistuhe, 
hemorrhoids,  exuding  blood  or  pus,  etc.,  the  finger  is  gently  inserted, 
overcoming  gradually  the  spasm  of  the  sphincter  which  always  occurs 
and  which  must  not  be  taken  for  .a  stricture.  The  tight  grip  of  the  muscle 
on  the  finger  relaxes  during  the  examination  and  gives  considerably  more 
freedom  of  movement.  Examining  as  a  routine  the  prostate  and  bladder, 
or  the  uterus,  one  may  at  once  exclude  or  determine  conditions  affecting 
those  organs;  then,  sweeping  around  to  either  side  one  feels  for  points  of 
tenderness,  irregularities  on  the  smooth  wall  of  the  bowel,  dilated  veins, 
fistulous  communications,  polypi,  etc.  The  finger  is  then  turned  toward 
the  back  of  the  rectum.  The  position  and  condition  of  the  coccyx  should 
always  be  determined  during  any  rectal  examination.  Various  obstetrical, 
genito-urinary,  and  gynaecological  examinations  may  be  made  by  way  of 
the  rectum.  The  fact  that  impacted  ureteral  calculi  can  at  times  be  per- 
ceived by  the  examining  finger  if  caught  in  the  bladder  wall  or  in  the 
neighborhood  of  the  pelvic  brim  must  be  mentioned.  Too  little  considera- 
tion is  given  to  a  rectal  examination  in  appendicitis  and  appendicular 
complications.  An  appendix  abscess  extending  downward,  though  often 
painless,  is  frequently  associated  with  an  extreme  tenderness  when  touched 
by  the  examining  finger.  This  tenderness  is  usually  too  localized  to  be 
confused  with  any  general  abdominal  distress,  and  its  high  position  to  the 
righl   is  of  diagnostic  significance. 

The  examining  finger  has  firsl  1-1',  inches  of  contracted  sphincter 
area  to  overcome.  A  -low  inserting  movemenl  dilates  the  muscles  with- 
out pain,  and  allows  the  examine!-  and  patient  to  appreciate  localized 
tender  areas,  such  as  are  occasioned  by  fistulae,  or  ulcerations  of  hemor- 
rhoidal veins.  A  forcible  dilatation  would  readily,  bj  the  pain  occasioned, 
prevent  the  disclosure  of  many  of  these  minor  conditions.  Beyond  the 
sphincters  the  finger  has  free  play  and  :it  times  one  fails  to  touch  any 
part  of  the  bowel,  tin-  rectum  being  ballooned  by  flatus;   by  crooking  the 


224  MEDICAL  DIAGNOSIS. 

finger  one  touches  readily  the  rectal  wall.  It  is  at  times  possible  to  dis- 
tinguish emptied  fallen  coils  of  small  intestines  in  the  pelvis  by  rectal 
examination;  such  a  condition  may  take  place  when  a  complete  stricture 
has  occurred  high  up  in  the  small  intestine,  the  empty  tract  below  col- 
lapsing and  descending. 

Indirectly  both  the  small  and  large  bowel  can  be  examined  through 
the  abdominal  wall  by  inspection  and  palpation.  Auscultation  has  but  a 
doubtful  bearing  on  abdominal  conditions;  even  marked  intestinal  dis- 
orders may  yield  nothing  to  the  most  experienced.  On  the  other  hand, 
correct  interpretations  of  simple  existing  phenomena  may  give  most 
important  results.  Inspection  is  always  preferably  performed  with  the 
patient  lying  on  his  back,  with  his  knees  either  flexed  or  extended.  (See 
Methods  of  Physical  Diagnosis.) 

Examination  of  the  large  intestine  and  the  csecal  region  is  helped  by 
the  easily  applied  method  of  inflation.  Before  this  procedure  a  thorough 
purging  is  always  advisable.  The  soft  rubber  rectal  tubes,  \  to  ^  inch  in 
diameter,  with  two  or  more  lateral  openings,  and  connected  with  a  David- 
son syringe  or  a  double  or  single  atomizer  bulb,  can  be  inserted  to  any 
distance  desired.  A  slow  twisting  insertion  will  quickly  put  the  openings 
above  the  anus  and  sphincters.  Since  the  sigmoid  flexure  is  the  most 
commonly  dilated  part  of  the  bowel,  inflation  should  begin  while  the  tube 
is  entering  the  flexure,  and  the  first  examination  directed  to  this  part. 
Unless  previously  distended  by  gas  or  continued  fecal  accumulations  the 
sigmoid  flexure  should  not  rise  easily  out  of  the  pelvis  during  inflation. 
Usually  when  a  point  half  way  between  the  groin  and  the  umbilicus  is 
reached  distinct  discomfort  is  felt  unless  relieved  by  passage  of  the  air 
upward.  In  many  instances  it  will  be  found  that  the  inflating  air  passes 
readily  beyond  the  sigmoid  and  shows  its  presence  in  the  descending  and 
transverse  colon.  It  is'  now  generally  conceded  that  the  ileocecal  valve 
allows  air  to  pass  during  the  process  of  inflation  and  its  passage  can  at 
times  be  heard  with  the  stethoscope  applied  in  the  right  iliac  fossa. 

To  further  inflate  the  colon  the  rectal  tube  may  be  passed  upward 
its  whole  length;  we  cannot  be  sure,  however,  that  it  will  pass  beyond 
the  splenic  flexure  nor  could  further  passage  be  expected.  Inflation  of 
the  transverse  and  ascending  colon  and  of  the  caecum  take  place  quite 
readily  with  the  tube  in  this  locality.  The  pain  of  extreme  distention  will 
always  warn  the  operator  when  to  temporarily  moderate  the  air-pressure, 
which,  however,  is  usually  relieved  at  this  stage  by  the  passage  of  air 
upward  through  the  ileocecal  valve.  Detaching  the  rectal  tube  from  the 
inflating  apparatus  allows  the  bowel  to  return  to  its  normal  state,  by 
expelling  the  contained  air. 

Carefully  applied  inflation  in  connection  with  inspection  and  palpa- 
tion may  give  important  results.  Idiopathic  dilatation  of  the  sigmoid 
flexure  can  be  readily  differentiated  from  abdominal  distention  due  to 
other  causes,  the  sigmoid  clearly  outlining  itself  as  it  rises  from  and  descends 
again  into  the  left  iliac  fossa,  often  overlying  the  rest  of  the  abdominal 
contents  in  its  sweep  upward  and  to  the  right.  Tumors,  malignant  or 
other  strictures  of  the  bowel,  fecal  accumulations  may  be  brought  up  from 
the  pelvis  into  sight  and  touch.    The  position  of  the  colon  and  caecum  can 


THE  STOMACH  AND  INTESTINES.  225 

be  readily  outlined,  visibly  in  thin  subjects,  by  percussion  and  palpation 
in  those  stouter  and  more  muscular,  although  the  examiner  can  always  see 
that  inflation  is  going  on  by  the  puffing  up  of  the  various  regions.  One 
must  know  that  at  both  the  splenic  and  hepatic  flexure  the  bowel  will  be 
less  prominent  than  elsewhere.  The  same  pathological  conditions  men- 
tioned in  connection  with  the  sigmoid  flexure  may  be  shown  in  the  colon. 
One  would  naturally  expect  that  complete  strictures  from  any  cause 
would  prevent  passage  of  air  upward  or  downward.  In  such  cases  the 
distention  and  condition  (muscular  hypertrophy,  visible  peristalsis)  above 
the  stricture  may  tell  us  as  much  or  more  than  inflation  from  below;  and 
further,  in  such  conditions  the  diagnosis  is  rarely  in  doubt.  Incomplete 
or  partial  strictures,  whose  symptoms  may  be  very  obscure,  are  at  times 
clearly  brought  out  by  the  rapid  inflation  from  below,  as  a  sudden  nar- 
rowing above  the  dilated  lower  part. 

Easily  recognized  is  the  displacement  of  the  colon,  particularly  the 
transverse  colon  in  enteroptosis.  The  transverse  colon  may  lie  below 
the  umbilicus,  or  even  in  the  pelvis,  the  common  appearance  on  inflation 
being  a  shallow  V-shaped  protuberance,  the  arms  of  the  V  running  up  to 
the  liver  and  spleen.  The  relation  of  the  bowel  to  retroperitoneal  and 
other  tumors  is  more  easily  determined  by  inflation  than  by  any  other 
means.  Inflation  of  the  bowel  above  the  ileocsecal  valve  doubtless  may  be 
of  value.  Its  application  has  given  but  uncertain  results.  Inflation  of 
the  bowel  as  a  test  for  perforation  is  now  universally  condemned.  Many 
cases  of  flatulence  supposedly  due  to  gastric  distention  can  be  found  to  be 
due  to  distention  of  the  colon.  Inflation  is  a  valuable  aid  in  the  differ- 
ential diagnosis  of  these  conditions. 

Roxtgex-ray  Examinatiox  of  the  Intestixes. — Large  and  small 
solid  tumors,  thickening  and  muscular  hypertrophy  can  at  times  be 
made  out  by  the  fluoroscope  or  in  skiagrams.  The  data  obtained  by  this 
method  are,  however,  usually  confirmative  of  facts  elicited  b}r  the  anam- 
nesis and  the  above  described  methods.  Scybalous  masses  present  no 
different  shadow  from  that  of  organic  disease.  Lining  the  intestine  by 
continuous  doses  of  bismuth  allows  the  coils  to  be  readily  photographed, 
and  under  this  condition  peristalsis  can  be  readily  observed  by  the  fluoro- 
scope and  the  rate  of  progress  of  fecal  matter  observed.  More  feasible 
and  of  distinct  value  in  recognizing  displacements  of  the  colon  is  the 
injection  of  suspensions  of  bismuth  in  large  quantities.  Very  serviceable 
photographs  can  be  secured  by  this  method.  Localization  of  small  metallic 
or  other  solid  foreign  bodies  in  the  intestines  is  remarkably  facilitated  by 
the  X-rays. 

So-called  "test  lavage"  is  used  at  times  to  bring  away  secretion  or 
material  from  the  large  bowel:  mucus,  blood,  ulcerating  fragments  of  new 
growths.  The  examination  of  the  sediment  of  such  washings  at  times 
gives  distincl  help.    It  can  only  !»•  satisfactorily  performed  when  the  large 

bowel   has  been  previously  completely  emptied. 

It  has  been  suggested  that  dilatation  of  the  duodenum,  with  stricture 
beyond,  c;m  be  diagnosed  by  filling  the  stomach  and  duodenum  with  water 
through  a  Btomach-tube.     Dulness  and  distention  toward  or  in  the  right 

hypochondriuni  and   the  fact    that   the  fluid   may   return   as  does   the   fluid 
15 


226  MEDICAL  DIAGNOSIS. 

from  an  hour-glass  stomach,  part  at  once  and  the  rest  a  few  minutes  later, 
is  considered  suggestive.  An  inflation  that  outlines  the  stomach  and 
produces  an  extra  prominence  in  the  right  hypochondrium  would  be 
equally  suggestive. 

Faeces. — The  accurate  determination  of  many  points  with  regard  to  the 
faeces  is  difficult,  owing  to  the  wide  variations  in  their  composition  and  to 
the  fact  that  the  establishment  of  a  normal  or  standard  bowel  movement 
requires  the  continued  administration  of  certain  standard  diets  for  several 
successive  days. 

Various  standard  diets  are  recommended,  the  simplest  being  milk, 
since  it  contains  fat,  proteids,  and  carbohydrates. 

1.  Milk,  8  oz.  every  two  hours  from  8  a.m.  to  10  p.m.,  amounting  to 
4  pints  in  the  twenty-four  hours. 

2.  That  of  Schmidt  is  more  complicated,  but  approaches  more  nearly 
a  general  diet: 

7.30  a.m.     Milk,  17§  oz.,  and  6  biscuits. 

9.00  a.m.     Gruel,  1^  oz.  oatmeal,  1  egg,  2  biscuits,  J  oz.  butter,  7  oz.  milk,  10£  oz. 

water. 
1.00  p.m.     Minced  beef,  4\  oz.  raw  weight,  lightly  fried  in  J  oz.  butter,  leaving  the 

interior  raw,  and  potato  puree — 7  oz.  mashed  potatoes,  7  oz.  milk, 

§  oz.  butter. 
4.30  p.m.     Milk,  17J  oz. 
7.30  p.m.    Same  as  at  9  a.m. 

3.  A  "mixed  diet"  is  more  liberal  and  better  borne,  but  the  neces- 
sary cooking  makes  the  eventual  microscopical  examination  much  less 
satisfactory  than  either  of  the  preceding: 

10  oz.  hot  water. 

3  oz.  fresh  fish,  4  biscuits,  §  oz.  butter,  10  oz.  tea,  2  oz.  milk. 

10  oz.  hot  water. 

3  oz.  mutton,  3  oz.  cabbage,  4  biscuits,  §  oz.  butter,  rice  pudding  (h  oz. 

rice  in  10  oz.  milk). 
10  oz.  tea,  2  oz.  milk,  2  biscuits. 
10  oz.  hot  water. 
3  oz.  fresh  fish,  3  oz.  chicken,  3  oz.  spinach,  rice  pudding  (as  before),  2 

biscuits,  I  oz.  butter. 
10  oz.  milk. 

4.  A  meat  diet:  {  lb.  finely  minced  beef  every  three  hours  and  10  ounces 
hot  water  one  hour  before  meal-time.    It  contains  no  carbohydrates. 

The  first  dejecta  usually  appear  in  from  twenty-four  to  forty  hours 
after  the  standard  meal  has  been  given.  Radioscopic  examination  of  the 
intestine  and  the  passage  of  its  contents  shows  that  in  about  seven  hours 
the  ileocecal  valve  has  been  reached  by  part  of  the  residue,  which  may 
now  remain  four  hours  in  the  colon,  three  hours  in  the  sigmoid  flexure  and 
rectum  before  being  expelled. 

Attempts  to  describe  bowel  movements  resulting  from  standard  diets 
have  been  made. 

1.  Faeces  Resulting  from  Milk  Diet. 

Amount. — ■ 

Quantity  of  milk  in  24  hrs.  Fseces  excreted,  average  weight  in  Gm. 

4  pints  135.2  Gm. 

5  pints  151      Gm. 

6  pints  198     Gm. 


8.00 

A.M. 

9.00 

A.M. 

12.00 

M. 

1.00 

P.M. 

4.30 

P.M. 

6.00 

P.M. 

7.00 

P.M. 

10.00 

P.M. 

THE  STOMACH  AND  INTESTINES.  227 

Color. — Yellow-white,  or  white  tinged  with  orange. 

Consistency. — Not  well  formed,  tending  to  be  lumpy;  rolls  of  fecal 
matter  not  homogeneous  but  composed  of  lumps  welded  together,  or  firm 
sausage-shaped  masses  plus  soft  paste. 

Odor. — Not  offensive;   more  like  stale  cheese  than  faeces. 

If  constipation  exists,  a  tendency  to  isolated  scybala  of  pale  coloi  is 
seen,  often  firm,  hard,  and  dry  enough  to  rattle  in  the  vessel,  and  to  break 
up  like  dry  clay,  with  an  earthy  odor. 

With  diarrhoea  a  milk  diet  gives  fasces  resembling  Devonshire  cream — 
sticky,  but  capable  of  being  poured  from  one  vessel  to  another.  Gas  bubbles 
and  froth  are  seen  on  shaking,  and  the  odor  is  that  of  decomposed  cheese 
or  putrid  proteid. 

Caseous  flocculi,  the  evidences  of  disturbed  digestion,  are  readily 
recognized  as  bright  white,  small,  fibrillary-looking,  friable  masses. 

2.  Faeces  Resulting  from  the  Schmidt  Diet. 

Amount. — Smaller  than  that  from  the  milk  diet.     Average  90  Gm. 

Color. — Light  brownish-yellow,  darker  on  the  outside  than  inside. 

Consiste?icy. — Well  formed  rolls  or  sausage-shaped  masses,  as  a  rule. 
These  readily  break  up  on  drying. 

Odor. — Distinctly  fecal. 

In  constipation  on  a  Schmidt  diet  lumps  of  fecal  matter  are  massed 
together,  or  isolated  scybala  are  seen. 

In  diarrhoea  on  this  diet  the  faeces  resemble  closely  those  of  a  patient 
on  a  milk  diet. 

3.  F.eces  Resulting  from  a  Mixed  Diet. 
Amount. — Average  102  Gm. 

Color.  —  Nut-brown,  olive-green  (chlorophyll  of  vegetables),  varies 
much  from  day  to  day. 

Consistency  and  Form. — Usually  large,  firm,  roll  or  sausage-like  motions. 
On  drying  break  up  easily. 

Odor. — Fecal. 

In  constipation  the  faeces  of  a  mixed  diet  are  usually  dark  brown  or 
black  scybala  with  pressure  facets  and  mucus  in  the  crevices.  They  may 
be  of  stony  hardness  and  not  offensive. 

In  diarrhoea  the  motions  are  dark  brown  or  nearly  black,  of  thick- 
sticky  or  pasty  consistence  with  small  scybala.  Soft  movements  in  general 
from  a  mixed  diet  have  most  offensive  odors.  An  increase  of  the  quantity 
of  milk  in  mixed  diets  makes  the  stools  paler  and  less  firm. 

4.  Meat  Diet. 

Amount. — Average  54  Gm. 

Color. — Dark  brown  to  black. 

Consist' nr y  and  Form.     Firm  rolls,  2  to  3  inches  in  length. 

Odor. — Fecal  but  very  offensive. 

Variations  in  consistency  and  form,  in  odor,  and  in  color  naturally 
depend  on  local  conditions  and  the  time  the  fecal  material  is  retained  in 
the  large  bowel.  The  amount  is  important,  but  several  days  are  required 
to  o;ot  the  proper  average.  The  formation  of  scybala,  according  to  these 
results,  may  take  place  in  a  very  few  days. 


228  MEDICAL  DIAGNOSIS. 

The  faeces  are  composed  of: 

1.  Food  remains. 

(a)  Indigestible  remnants. 

(b)  Digestible  but  not  absorbed  remains. 

2.  The  remains  of  the  digestive  secretion. 

3.  Products  resulting  from  the  digestion  of  food  in  the  intestinal  canal. 

4.  Formed  and  unformed  products  of  the  intestinal  mucosa. 

5.  Bacteria. 

6.  Various  substances  introduced  accidentally  from  without;  various 
concrements,  gall-stones,  intestinal  stones,  parasites,  cotton,  wool,  or  linen 
fibres. 

The  faeces  are  collected  in  a  bed-pan  or  any  large  clean  vessel. 

In  the  study  of  any  question  of  absorption  or  excretion  the  rule  is 
to  place  the  patient  on  one  of  the  standard  diets  for  at  least  four  days 
before  beginning  any  estimation.  The  administration  of  some  coloring 
matter  such  as  charcoal  or  carmine  with  the  first  meals  of  the  standard 
diet  will  render  easy  the  recognition  of  their  first  dejecta. 

The  faeces  are  to  be  examined  macroscopically,  microscopically,  and 
chemically. 

Fermentation. — Normal  firm  bowel  movements  will  usually  dry  with- 
out appreciable  gas  formation,  and  even  semisolid  or  pultaceous  stools  ordi- 
narily produce  only  a  small  amount.  A  stool  which  on  standing  shows 
evidence  of  fermentation  by  the  production  of  gas  bubbles  or  a  distinct 
frothy  layer,  or  gas  bubbles  in  such  abundance  as  to  give  a  pale  appearance 
to  a  more  or  less  solid  stool,  should  be  considered  pathological  and  examined 
for  fermentable  products — carbohydrates. 

Excess  of  neutral  fat  in  the  stools  can  be  readily  noted.  The  normal 
bowel  movement  leaves  no  greasy  mark  upon  a  vessel  containing  it.  Neu- 
tral fat  will  show  itself  in  the  gross  examination  either  as  a  very  pale,  white, 
distinctly  greasy  bowel  movement,  or  if  the  stool  be  liquid  the  fat  may 
rise  to  the  top,  forming  the  characteristic  appearance  of  melted  fat,  and  on 
cooling  may  partially  or  completely  solidify.  The  soaps  in  ordinary  amounts 
and  the  fatty  acids  are  not  macroscopically  recognizable. 

Excess  of  proteids  in  the  faeces,  when  in  the  form  of  meat,  can  often 
be  recognized  by  the  appearance  of  numerous  reddish  points  throughout 
the  bowel  movement.  One  must  be  certain  that  other  coloring  or  colored 
matters  have  not  been  ingested.  Casein  shows  itself  as  the  familiar  white 
flocculi,  easily  disintegrated,  much  denser  white  than  mucus.  Undissolved 
connective  tissue  has  the  appearance  of  fine  cotton-wool  fibres  and  can  be 
removed  for  further  examination.  Other  substances  to  be  considered  in 
the  gross  examination  are  mucus,  blood,  pus,  foreign  bodies,  and  parasites. 
Small  amounts  of  mucus  are  always  present,  but  require  search  to  demon- 
strate their  presence.  A  constipated  stool  often  shows  flakes  of  dense 
white  mucus  in  the  interstices  of  the  firm  masses,  or  mucus  may  follow  the 
movement. 

Brownish,  gelatinous-looking  mucus,  colored  by  the  bile  pigments, 
usually  comes  from  the  small  intestine;  colorless  mucus  and  that  appear- 
ing as  denser,  whiter  masses  and  flakes,  from  the  colon.  Tubular  masses 
from  the  large  intestine,  sometimes  many  centimetres  in  length,  are  seen 


THE  STOMACH  AND  INTESTINES.  229 

in  membranous  colitis.  Floating  or  softening  these  masses  or  strands 
in  water  will  usually  determine  their  character.  Unformed  mucus,  par- 
ticularly in  liquid  stools,  sometimes  on  standing  accumulates  in  masses 
as  large  as  a  hen's  egg. 

Fresh  blood  can  be  easily  recognized.  Unless  quickly  voided,  blood 
in  the  intestines  becomes  black  and  small  amounts  do  not  show  in  the 
stools.  Large  amounts  appear  as  "tarry  stools" — large  black  masses, 
clots  too  large  to  be  broken  up  or  absorbed. 

Pus  is  usually  quickly  disintegrated.  Fresh  pus  which  retains  its 
appearance  is  practically  always  from  the  sigmoid  or  rectum. 

Parasites  are  described  in  another  section.  Many  food  remains  are 
detected  at  a  glance:  fruit  stones  and  seeds,  skin  of  fruit,  vegetables,  food 
pulp  of  oranges,  grape  fruit,  lemons,  large  masses  of  connective  tissue, 
bones,  etc. 

For  the  more  careful  examination  various  simple  plans  are  recom- 
mended. In  examining  the  whole  quantity  of  faeces  an  ordinary  fine  sieve 
on  which  running  water  can  play  enables  one  to  collect  the  larger  foreign 
bodies  and  solid  material;  or  the  fasces  are  placed  in  a  large  vessel  with 
water  and  thoroughly  broken  up.  Mucus,  woody  fibres,  smaller  seeds,  and 
bacteria  float  and  can  be  removed  by  pouring  off  after  settling.  By  repeat- 
ing the  process  several  times  a  residue  of  solid  matter,  deodorized  and 
decolorized,  is  obtained.  Gall-stones,  pancreatic  calculi,  muscle  fibres, 
connective  tissue,  casein,  parasites,  are  easily  looked  for  in  this  way. 

Spreading  the  faeces  on  a  glass  plate  with  a  dark  background  facilitates 
the  examination.  Pieces  of  connective  tissue,  muscle  fibres,  casein,  foreign 
bodies,  or  anything  differing  from  the  homogeneous  fecal  matter  may  be 
readily  found  in  this  way. 

Microscopical  Examination. — Mixed  Diet. — A  small  piece  of  fecal 
matter  can  be  taken  from  the  stool  after  it  has  been  mixed  in  a  mortar  or 
a  vessel,  or  several  loopsful  of  a  liquid  stool  can  be  smeared  on  a  slide. 
A  cover-glass  is  preferable  if  high  power  is  used.  For  a  low-power  exami- 
nation a  glass  3  or  4  inches  square  on  which  a  comparatively  large  amount 
of  faeces  has  been  thinly  spread,  can  be  placed  on  the  stage  of  the  microscope. 
A  large  area  can  be  quickly  gone  over  in  this  way. 

Masses  of  mucus,  blood,  or  pus,  meat  fibres,  etc.,  should  be  picked  off 
for  separate  examination  before  mixing  the  fecal  material.  Schmidt 
recommends  taking  three  separate  specimens  of  softened  faeces.  No.  1  is 
examined  direct.  In  it  we  can  note  much  fibre,  colorless  soaps,  neutral 
fat  if  present,  small  and  large  yellow  salts  of  calcium.  No.  2  is  stirred 
with  a  small  drop  of  30  per  cent,  acetic  acid  heated  for  a  moment  until 
it  begins  to  boil,  then  covered  with  a  cover-glass.  After  cooling,  small 
flukes  of  fatty  acids  appear.  The  soap  flakes  and  calcium  salts  will  have 
disappeared.  No.  3  is  rubbed  up  with  a  drop  of  Lugol's  solution.  Under 
the  microscope  unaltered  starch  will  assume  a  violet  color. 

Since  85  pei  cent,  or  more  of  the  food  is  digested  and  absorbed,  and 
since  of  the  remainder  a  portion  is  in  the  shape  of  products — albumoses, 
fatty  acid,  soaps,  dextrin,  etc..  little  unaltered  food  is  present  in  the  speci- 
men. Easily  recognized  are  the  bacteria  which  make  up  practically  one- 
third  of  the  dry  substance  of  the  stool.     Acid-fast  bacilli  may  be  tubercle 


230  MEDICAL  DIAGNOSIS. 

or  smegma  bacilli.  Leptothrix  threads  are  easily  recognized.  Epithelial 
cells  in  considerable  numbers  are  always  present.  They  are  usually  of  the 
smaller  round  type,  and  show  evidences  of  digestion  or  disintegration. 
No  deduction  can  be  drawn  from  their  number  or  form  as  to  conditions  in 
the  bowel.  Squamous  epithelia  from  the  mouth  or  from  the  food  are 
occasionally  seen.  Structureless  or  faintly  striated  mucus  in  small  amounts, 
bile-stained  if  from  parts  high  up,  pale  if  from  lower  down,  may,  by  the 
number  of  leucocytes  or  epithelial  cells  entangled  in  it,  give  evidence  of 
catarrhal  conditions  of  the  bowels.  Mucus  is  less  dense,  less  sharp  in  outline 
than  connective  tissue;  acetic  acid  causes  it  to  show  faint  striations.  A 
few  leucocytes  are  always  present. 

Food  Remains.  —  Undigestible  remnants  of  any  kind  may  appear. 
Many  of  them  are  recognizable  macroscopically.  The  framework  of  vege- 
tables gives  most  varied  pictures.  Many  of  the  structures  suggest  parasites 
and  have  frequently  been  mistaken  for  them.  Remnants  of  undigested 
starch  may  be  suspected  by  their  pallid  color  and  their  cellular  envelope. 
It  is  well  to  stain  suspicious  specimens  with  iodine  and  look  for  the  blue 
stained  masses;  to  judge  whether  starch  is  being  excreted  in  excess  is  not 
easy  with  the  microscope;  the  fermentation  test  is  the  more  accurate 
method. 

Two  or  three  small  meat  fibres  in  a  field,  showing  very  dim  or  no  stria- 
tion,  and  with  no  remnants  of  nuclei,  may  be  considered  normal  in  patients 
on  a  mixed  diet.  Retention  of  the  striation,  persistence  of  the  nuclei  in 
good  condition,  and  presence  of  meat  fibres  in  numbers  suggest  disturbance 
of  intestinal  digestion,  particularly  that  part  related  to  the  pancreas.  It 
is  not  likely  that  anacidity  of  the  gastric  juice  will  show  the  same  condition. 
Specimens  from  faeces  of  patients  with  pancreatic  derangements  may  show 
meat  fibres  in  such  numbers  that  counting  them  in  one  field  may  be  difficult 
or  impossible.  Some  cases'  show  excess  of  meat  fibres  in  the  stools  if  over 
60  grammes  of  meat  are  taken  per  day. 

Schmidt's  Nucleus  Test  for  Pancreatic  Disease  or  Impairment  of  Pan- 
creatic Function. — The  disintegration  or  non-disintegration  of  the  meat 
fibre  nuclei  in  the  centre  of  small  balls  of  meat  of  standard  size — \  to  h  inch 
in  diameter — kept  together  by  non-digestible  netting  and  given  in  the  food, 
cannot  be  said  to  be  positive  enough  for  any  certain  deductions  to  be  made. 
We  can  only  say  that  if  all  the  nuclei,  even  those  on  the  outside  of  the  balls, 
are  found  unaffected  by  digestion,  pancreatic  insufficiency  is  suggested. 
Connective  tissue  and  elastic  tissue  are  constantly  present  on  a  mixed  diet, 
though  in  very  small  amounts.  They  are  readily  recognized  by  their  dense 
and  fibrillated  appearance.  Gastric  juice  readily  digests  connective  tissue, 
and  its  persistent  presence  in  large  quantity  must  be  taken  as  pointing  to 
impaired  gastric  digestion.  A  few  fat  drops  may  be  found  on  a  mixed  or 
meat  diet,  but  more  than  eight  to  ten  fat  drops  in  a  single  field  should 
attract  attention.  This  neutral  fat  is  easily  seen  as  yellowish,  oily  looking 
drops  of  varying  size  and  shape.  Constant  presence  of  the  flakes  of  the 
•'higher  melting  point"  fat,  and  the  flaky  needle-like  crystals  of  the  fatty 
acids,  or  of  the  flake  or  disk  crystals  of  the  soaps,  is  to  be  considered  as 
abnormal.  Gentle  heating  of  the  slide  will  dissolve  the  crystals  and  flakes 
of  the  fatty  acid  and  soap.    Triple  phosphate  crystals,  colorless  and  of 


THE  STOMACH  AND  INTESTINES.  231 

characteristic  shape,  neutral  phosphate  of  lime  crystals,  colorless,  or  the 
yellow  calcium  salts  (sometimes  bile  stained)  are  commonly  found.  Oxal- 
ate of  lime  crystals  are  usual  in  a  mixed  diet.  Their  presence  in  the  faeces 
when  no  vegetables  are  being  eaten  is  said  to  indicate  some  intestinal 
disorder.  Cholesterin  crystals,  Charcot-Leyden  crystals,  especially  if  much 
mucin  is  present,  are  both  found  in  the  faeces.  Very  frequently  present  are 
the  so-called  "yellow  bodies":  large  lumps  of  bright  yellow  material, 
structureless,  often  surrounded  by  mucus,  and  recognized  macroscopically. 
They  give  a  proteid  reaction.  They  are  considered  to  be  albumin,  bile 
stained,  and,  when  in  great  amount  together  with  much  mucus,  indicate 
some  disturbance  of  proteid  digestion. 

Casein  flocculi  are  seen  microscopically  as  almost  structureless 
masses,    finely    fibrillated    and    enclosing    fat    droplets    in   their    meshes. 

Hairs,  cotton  and  linen  fibres,  are  common  in  the  stools,  being 
taken  in  with  the  food  in  large  numbers. 

Chemical  Examination. —In  health 
the  faeces  have  a  neutral  or  faintly  alka- 
line reaction.  On  standing  this  becomes 
faintly  acid.  Stools  with  excess  of  car- 
bohydrates ferment  and  give  a  strong 
acid  reaction.  Excess  of  fat,  fatty  acid, 
gives  faintly  acid  stools.  Decomposition 
of  excess  of  proteid  matter  produces  an 
alkaline  reaction.  A  mixed  diet  in  health 
causes  neutral  faeces;  a  pure  proteid  diet 
produces  alkaline  faeces;  a  pure  carbo- 
hydrate diet  produces  acid  faeces;  a  diet 
of  fats  produces  acid  faeces.    Only  freshly 

i    ,.  !  ,    .  ,.  A         Fi<;.  91. — Charcot-Levdcn  crystals  from  the 

passed  faeces  can  be  used  in  testing.    A  stools.      4uu.— Emeis,,.i. 

markedly  acid   reaction   in  fresh  faeces 

suggests  fermentative  changes  from  undigested  carbohydrates.  "  Acid 
diarrhoeas,"  so-called,  may  be  associated  with  hyperacidity  of  the  stomach 
and  insufficiency  of  the  biliary  and  pancreatic  secretion. 

The  test  for  hydrobilirubin  or  the  bile  products  is  important,  since  they 
may  be  present  in  colorless  stools.  The  faeces  are  stirred  up  with  a  concen- 
t rated  solution  of  mercuric  chloride;  normal  faeces  are  colored  rod;  faeces 
containing  unchanged  bilirubin  become  green.  The  pale  stool  of  the  leuco- 
hydrobilirubin  gives  the  red  reaction.  Absence  of  the  red  or  green  coloring 
i-  seen  in  fatty  stools  with  complete  acholia. 

Composition. — From  74  to  84  per  cent,  of  the  faeces  is  water;  16-26 
per  cent,  is  dry  substance.  Of  the  dry  substance  10-20  per  cent,  can  be 
extracted  with  ether,  i.e.,  are  fats.  Over  90  per  cent,  of  fats  taken  in  are 
absorbed. 

Fnis. — Qualitative  tests  only  can  be  considered.  The  fats  are  readily 
detected  macroscopically  and  microscopically.  They  are  excreted  as 
neutral  fats,  soaps,  and  fatty  acids.  These  have  been  described.  Crystals 
and  flakes  melt  readily.  Extracting  a  small  mass  of  faeces  with  ether  and 
pouring  the  ether  through  a  piece  of  filter  paper  will,  if  fats  are  in  excess, 
give  the  characteristic  appearance  of  oil  on  the  paper. 


r     ■ 

V 

-.  / 

- 

: 

232  MEDICAL  DIAGNOSIS. 

From  2  to  6  per  cent,  of  the  dry  substance  is  carbohydrate,  usually 
dextrin.  Tincture  of  iodine  or  Lugol's  solution  will  stain  unaltered  starch 
blue;  dextrin  remains  red.  There  is  no  reaction  for  sugar.  Fermentation 
is  the  simplest  test  for  excess  of  carbohydrate  or  carbohydrate  residue. 
Schmidt's  fermentation  tube  may  be  employed  or  one  may  note  carefully 
the  presence  of  gas  formation  in  the  freshly  passed  stool. 

Proteids. — More  than  85  per  cent,  of  proteids  taken  into  the  body  are 
absorbed.  The  proteid  residue  in  health  is  partly  from  the  food,  partly 
from  the  disintegration  of  proteids  of  the  body — leucin,  tyrosin,  indol, 
skatol,  mucin,  nuclein.  Albumin  and  globulins,  and  their  transformative 
products,  albumoses,  peptones,  are  not  found  normally.  Their  presence  in 
the  stools  means  either  insufficient  proteid  digestion  and  absorption,  or  that 
the  " postdigestive  putrefaction"  in  the  large  intestine  has  not  had  time  to 
take  place.  The  simple  tests  for  albumin  and  albumose  can  be  applied  after 
dissolving,  mixing  a  small  amount  of  fecal  material  in  water,  and  filtering. 
Any  inflammatory  condition  of  the  lower  bowel  will  yield  albumin  in  the 
faeces.  Serous  exudation  higher  up  may  undergo  the  natural  digestive  proc- 
esses. Persistent  intense  diarrhoea,  choleraic  diarrhoea,  can  hurry  materials 
through  before  digestion  of  albumin  or  albumoses  has  progressed,  and  faeces 
from  these  conditions  may  give  albumin  reactions  from  food  taken  or  from 
serous  exudation  into  the  bowel  as  in  typhoid  fever,  cholera,  or  dysentery. 

"Total  nitrogen"  estimations  are  necessary  to  determine  the  relation 
of  proteid  output  and  intake.  As  of  the  fats  and  carbohydrates  one  can 
say  of  the  proteids — for  clinical  purposes  macro-  and  microscopical  exami- 
nations yield  more  useful  information. 

Digestive  ferments  are  not  found.  The  pigmentary  remains  of  the  bile 
have  been  spoken  of.  Mention  has  been  made  of  the  various  salts  and  crys- 
tals, phosphates,  oxalates,  cholesterin,  etc.,  visible  microscopically,  remains 
of  food  digested,  or  of  digestive  procedure.  Chemical  tests  show  presence  of 
bile  salts,  bile  acids,  leucin,  tyrosin,  xanthin,  carnin,  and  proteid  derivatives. 

Occult  Blood. — The  most  important  chemical  examination  for  practical 
purposes.  Teichman's  acid-haemin  test  may  be  used,  but  others  are  simpler 
and  more  certain.  They  all  depend  upon  altered  haemoglobin  reactions. 
No  examination  of  faeces  can  be  considered  complete  unless  a  blood  test 
has  been  made;  since  occult  bleeding  may  go  on  indefinitely  with  no  gross 
signs  of  blood  in  the  faeces  and  no  blood-corpuscles  to  be  seen  microscopi- 
cally. All  bleeding  from  the  nose,  gums,  pharynx,  lungs,  and  vagina  must 
be  excluded.  No  meat  can  be  taken  during  the  days  on  which  the  faeces 
are  tested.  It  is  best  to  wait  for  forty-eight  hours  or  to  mark  a  food  period 
by  giving  charcoal,  lycopodium,  or  carmine. 

To  perform  the  test  we  must  first  remove  gross  fat  by  shaking  with 
ether;  otherwise  the  final  ether  extract  may  be  clouded.  This  is  poured 
away  and  the  residue  is  used.  10  c.c.  of  fluid  faeces  or  5  c.c.  of  solid  faeces, 
broken  up  in  5  c.c.  water,  are  treated  with  3  c.c.  glacial  acetic  acid,  thor- 
oughly mixed  and  shaken.  This  dissolves  red  blood-cells  and  sets  free 
haemoglobin  or  makes  acid  haematin.  After  standing  a  few  minutes  excess 
of  ether,  20-30  c.c,  is  added  and  the  mixture  vigorously  shaken  and  then 
allowed  to  separate.  The  overlying  ether  is  poured  off  and  the  tests  made 
with  it  as  follows' 


UPPER  AIR-PASSAGES   AND   EAR.  233 

Turpentine-Guaiac  Test. — To  a  few  cubic  centimetres  of  the  above 
ethereal  extract  previously  treated  with  a  little  alcohol  are  added  10  drops 
of  freshly  made  guaiac  tincture  and  30  drops  of  turpentine.  In  the 
presence  of  blood  pigment  a  distinctly  blue  color  occurs.  Sources  of  error 
are  the  recent  eating  of  potatoes  or  other  starchy  food,  iron  as  a  medicine, 
or  the  presence  of  bile,  saliva,  milk,  pus  in  considerable  quantities,  and 
urobilin.    The  reaction  may  fail  in  the  presence  of  minute  traces  of  blood. 

Aloin  Test. — Klinge  and  Shaer. — This  test  is  extremely  delicate.  Foods 
containing  haemoglobin  and  all  vegetables  and  drugs  must  be  avoided  for 
several  days.  The  diet  period  must  be  determined  by  charcoal  or  lycopo- 
dium,  not  carmine.  From  1  to  1.5  c.c.  of  turpentine  are  superimposed  and 
then  0.5  c.c.  of  freshly  made  3  per  cent,  aloin  solution.  The  reaction  con- 
sists in  the  rapid  development  at  the  line  of  contact  of  a  bright  rose-red 
color.    In  a  doubtful  case  both  these  tests  may  be  used. 

Benzidin  Test. — Schlesinger  and  Holt's  Modification. — 1.  Concentrated 
Benzidin  Solution:  as  much  benzidin  (Merck's  benzidin  puriss.)  as  will  go 
on  tip  of  table  knife  in  2  c.c.  of  glacial  acetic  acid;  shake  lightly.  2.  Piece 
of  fasces  the  size  of  a  pea  (or  several  c.c.  of  a  distilled-water  extract)  sus- 
pended in  one-fifth  of  a  test-tube  of  water;  close  with  cotton  and  boil. 
3.  Ten  to  twelve  drops  of  benzidin  solution  put  in  test-tube  and  2-2.5  c.c. 
of  hydrogen  peroxide  (3  per  cent.)  added.  To  this  add  1-3  drops  of  boiled 
fasces  after  mixing  the  latter  by  slightly  shaking.  Green  to  blue  color  is 
positive  and  appears  in  two  minutes  in  a  blood  mixture  of  1-200,000 
strength;   hence  this  test  is  5-10  times  as  delicate  as  other  tests. 

In  ulcerating  carcinoma  ventriculi,  occult  blood  is  continually  present 
in  the  stools;  in  ulcus  ventriculi  there  are  intervals  in  which  no  occult 
blood  can  be  detected;  in  intestinal  tuberculosis  it  is  absent;  in  enteric- 
fever  it  may  occur  in  the  absence  of  gross  hemorrhage  or  may  antedate  the 
latter  by  twenty-four  or  forty-eight  hours. 


IV. 

THE    EXAMINATION    OF   THE    UPPER   AIR-PASSAGES   AND 

THE   EAR. 

RHINOSCOPY.     LARYNGOSCOPY.     OTOSCOPY. 

General  Considerations. — Local  affections  of  the  nose,  throat,  or  ear? 
may  give  rise  cither  to  local  or  constitutional  symptoms,  while  constitu- 
tional diseases  frequently  produce  local  manifestations.  For  this  reason 
dexterity  in  the  use  of  the  mechanical  means  by  which  we  are  enabled  i<> 
distinguish  between  the  manifestations  of  local  ami  constitutional  diseases, 
as  observed  in  these  organs,  is  of  no  less  importance  to  the  general  clinician 
than  to  t  he  specialist. 

The  instruments  employed  in  a  simple  examination  of  the  nose,  throat, 
larynx,  or  ear  an-  ;,  head  mirror  for  reflection  of  light,  tongue  depressor, 
laryngeal  mirror,  and  nasal  and  aural  specula.  They  are  of  varied  designs, 
but  any  instrument  to  which  the  physician  has  become  accustomed  will 


234  MEDICAL   DIAGNOSIS. 

usually  meet  the  requirements  of  ordinary  cases.  Of  far  greater  importance 
than  the  instrument  to  be  employed  is  its  careful  manipulation.  Every 
instrument  must  be  carefully  cleansed  in  the  presence  of  the  patient,  both 
before  and  after  using.  The  speculum  should  be  slightly  warmed  over  a 
spirit  flame  or  gas  burner  before  introduction  into  the  nose  or  ear. 

Either  natural  or  artificial  light,  if  sufficiently  strong,  can  be  con- 
densed and  reflected  by  the  mirror  to  the  point  or  area  to  be  examined, 
and  the  source  of  the  light  may  be  either  to  the  right  or  left  of  the  patient. 

The  Examination  of  the  Nose. 

Anterior  Rhinoscopy. — Excoriations  around  the  margin  of  the  nares 
are  usually  produced  by  acrid  secretions,  excessively  acid  or  alkaline,  which 
occur  in  the  course  of  various  infectious  diseases,  colds,  nasal  hydrorrhcea, 
syphilis,  etc.  Rhinoscopy  has  to  do  with  the  examination  of  the  interior 
of  the  nose,  for  which  purpose  it  is  necessary  to  dilate  the  nostrils,  one  at  a 
time,  with  a  bivalve  speculum,  using  care  to  avoid  injury  to  the  mucous 
membrane  or  unnecessarily  annoy  the  patient  by  overdistention. 

Structures  Observed. — Under  normal  conditions,  the  patient  sitting 
erect  before  the  operator,  with  the  head  tilted  slightly  backward,  the  dis- 
tended alee  should  present  clearly  to  view  the  lower  turbinates,  the  middle 
and  lower  meati  on  the  outer  walls,  the  area  opposite  to  these  on  the  septum, 
and  the  floor.  This  constitutes  about  the  lower  third  or  respiratory  portion 
of  the  nares.  The  area  just  within  the  nares  on  the  lower  anterior  margin 
of  the  septum  should  be  especially  examined  as  the  most  frequent  location 
of  the  source  of  hemorrhage. 

Tilting  the  patient's  head  backward  brings  into  view  the  upper  or 
olfactory  portion  of  the  nostrils,  the  middle  turbinate  and  superior  meatus, 
rarely  a  small  portion  of  the  superior  turbinate — the  close  proximity  of  the 
septum  and  outer  wall  preventing  an  exposed  view  of  the  ethmoid  and 
sphenoid  area,  superior  turbinate  and  points  of  entrance  to  the  frontal 
sinus.  It  is  this  space  that  we  frequently  find  bathed  in  pus  in  the  case  of 
purulent  sinusitis,  ethmoiditis,  or  antrum  disease.  As  a  rule,  an  accumu- 
lation of  pus  above  the  middle  turbinate  is  an  indication  of  disease  of  the 
ethmoid  or  frontal  sinus,  while  if  pus  collects  beneath  the  middle  turbinate 
its  source  is  probably  from  the  antrum  of  Highmore.  In  case  the  whole 
naris  is  bathed  in  the  purulent  secretion,  first  cleanse  the  nostril,  then  have 
the  patient  lean  forward  or  turn  the  head  well  toward  the  side  involved 
in  order  to  favor  the  discharge  of  fresh  pus  and  determine  its  origin  more 
clearly.  Nasal  polypi  most  frequently  originate  in  this  part  of  the  nares, 
at  the  marginal  mucosa  of  a  turbinate  which  has  undergone  mucoid  degen- 
eration from  necrotic  tissue  in  the  ethmoid  cells;  less  often  from  the  sphe- 
noid sinus,  which  lies  slightly  below  and  posterior  to  the  ethmoid  cells. 
Beneath  the  middle  turbinate  is  the  only  natural  opening  into  the  antrum 
of  Highmore — the  ostium  maxillare — which,  however,  in  many  cases  is  so 
obscure  as  to  be  found  with  difficulty  even  by  experienced  rhinologists. 
Occasionally  two  or  more  openings  enter  the  antrum  at  variable  points, 
even  as  high  as  the  floor  of  the  orbit.  The  inferior  meatus  is  important 
for  two  reasons:   first,  it  is  beneath  the  lower  turbinate  that  we  find  the 


UPPER  AIR-PASSAGES  AND  EAR. 


235 


nasal  opening  of  the  lachrymal  duct,  which  may  become  occluded  from 
either  an  acute  or  chronic  enlargement  of  the  turbinate;  second,  because 
of  the  thinness  of  the  bony  wall  dividing  the  nares  from  the  antrum  of 
Highmore,  through  which  a  cannula  may  be  easily  introduced  for  diag- 
nostic purposes  in  suspected  purulent  infection  of  the  sinus. 

If  on  first  looking  into  the  nose  the  view  is  obstructed  by  an  intumes- 
cent  condition  of  the  membrane,  which  is  found  in  nearly  every  local  con- 
gestion, whether  active  or  passive,  the  difficulty  of  obtaining  a  satisfactory 
view  will  be  greatly  obviated  by  the  introduction  of  a  small  pledget  of 
cotton  dipped  into  a  solution  of  cocaine  and  camphor,  each  two  grains  to 
the  ounce  of  liquid  albolene.  The  objection  to  the  adrenalin  preparations 
in  examination  is  threefold:  first,  it  frequently  acts  as  an  irritant,  throw- 
ing the  patient  into  a  violent  state  of  sneezing;    second,  by  the  intense 


Rear  of 
Choana        pharynx 


Upper  turbinate  bone 
Promontory  of  tube 

Rosenmuller's  fossa 

Middle  turbinate  bone 
Opening  of  Eustachian   - 
tube 

Lower  turbinate  bone 


Septum        Choana 
/ 


Upper  turbinate  bone 


Promontory  of  tube 


Rosenmuller's  fossa 
Middle  turbinate  bone 

Opening  of  Eustachian 

tube 

Lower  turbinate  bone 


Soft  palate 


Uvula 
Fir..  92. — Xormal   posterior  nares,  view  obtained  by  repeated  change  of  the  mirror. 


bleaching  of  the  membrane;  and,  thirdly,  because  of  the  aggravated  con- 
gestion which  follows  its  use.  All  the  accessory  cavities  herein  referred 
to  are  in  direct  communication  with  the  nares;  each  sinus  or  cell  is  lined 
by  mucous  membrane,  somewhat  modified  in  character  from  that  in  the 
uasal  chambers,  and  any  inflammatory  process  in  one  cavity  may  cause 
more  or  less  irritation  in  one  or  all  of  the  others. 

Posterior  Rhinoscopy. — To  examine  the  nasopharynx  there  are  needed 
a  head  mirror,  tongue  depressor,  and  rhinoscopic  mirror.  Some  persons 
arc  able  to  depress  their  tongues  by  voluntary  muscular  effort,  in  which 
case  the  depressor  is  not  needed.  There  is  also  a  greal  difference  in  the 
ability  of  individuals  to  relax  the  soft  palate  a1  will,  thus  allowing  an 
unobstructed  vision  in  the  mirror  of  the  vault  of  the  pharynx  and  the 
posterior  nares.  The  process  of  such  examinations  will  often  require  great 
patience  if  the  pharynx  he  hypersensitive,  since  the  slightesl  touch  with 
the  mirror  may  produce  gagging. 

Let  the  patient  sit  comfortably  in  the  chair  and  assure  him  that  there 
will  be  nothing  connected   with   the  examination   to  cause  either  pain  or 


236  MEDICAL  DIAGNOSIS. 

discomfort.  There  is  a  general  tendency  to  hold  the  breath  and  strain  on 
the  pharyngeal  muscles.  To  obviate  these  difficulties  explain  that  it  is 
important  to  allow  the  mouth  to  open  widely  and  easily,  without  the 
slightest  tension  of  the  jaw,  leaving  the  tongue  at  rest  in  its  natural  posi- 
tion, and  to  breathe  quietly  and  freely  through  the  mouth.  The  prob- 
ability is  that  after  this  reassurance  the  soft  palate  will  relax  to  its  normal 
position.  A  common  difficulty  consists  in  the  involuntary  retraction  of 
the  soft  palate  tightly  against  the  pharyngeal  wall  as  soon  as  the  mirror 
approaches  the  mouth,  and  its  retention  in  that  position  until  the  mirror 
is  withdrawn.  This  frequently  can  be  obviated  by  having  the  patient  close 
his  eyes.  Should  this  fail,  the  most  satisfactory  recourse  left  is  cocainiza- 
tion  to  a  degree  sufficient  to  relieve  the  hypersensitiveness,  when  with  a 
long  applicator,  bent  at  right  angles,  making  a  hook  about  three-fourths 
of  an  inch  long  on  the  end,  the  soft  palate  may  be  gently  drawn  for- 
ward, and  the  rhinoscope  placed  in  position  to  reflect  the  image  desired. 
It  is  always  better  to  twist  a  small  piece  of  cotton  on  the  retractor, 
which  being  dipped  into  a  bland  oil  will  prevent  injury  to  the  mucous 
membrane. 

Structures  Observed. — With  the  rhinoscope  just  below  and  posterior 
to  the  margin  of  the  soft  palate,  and  with  a  strong  light,  the  angle  of 
reflection  in  the  mirror  may  be  so  directed  by  manipulation  as  to  show  suc- 
cessively all  the  structures  in  the  nasopharynx,  viz.,  the  Eustachian  orifices 
on  the  extreme  outer  margins,  and  just  above  and  slightly  posterior  to 
these  the  fossa?  of  Rosenmuller,  which  are  occasionally  obstructed  by 
adhesive  bands;  in  each  naris  are  seen  the  middle  and  lower  turbinates, 
the  latter  being  indistinct  except  over  its  upper  half;  and  directly  pos- 
terior and  below  the  posterior  margin  of  the  septum  on  the  pharygneal 
wall  is  the  usual  position  of  the  pharyngeal  tonsil  or  adenoids.  Since  this 
lymphoid  structure  under  normal  conditions  undergoes  atrophy  about 
the  age  of  puberty,  when  observed  in  adults,  or  when  sufficiently  large 
in  children  to  interfere  with  nasal  respiration,  it  should  be  regarded  as 
pathologic.  Polypoid  growths  in  the  nasopharynx  originate  usually  from 
mucoid  degeneration  of  the  posterior  margins  of  the  middle  or  superior 
turbinates  or  from  the  posterior  ethmoid  cells;  fibromata,  sufficiently 
large  to  fill  the  entire  vault,  suspended  by  a  small  pedicle  and  hanging 
low  enough  in  the  oropharynx  for  the  lower  margin  to  be  seen  by  direct 
vision,  are  not  infrequently  observed.  Posterior  rhinoscopy  is  seldom 
accomplished  in  children  with  any  degree  of  satisfaction,  in  which  case 
ocular  inspection  must  be  supplanted  by  digital  examination. 

Laryngoscopy. 

For  the  examination  of  the  laryngopharynx,  larynx,  and  trachea 
the  same  instruments  are  required  as  those  used  for  posterior  rhinoscopy, 
and  the  same  precautions  toward  preventing  nervousness  on  the  part  of 
the  patient  during  examination  are  of  even  greater  importance.  The 
tongue  depressor  will  not  be  needed  in  all  cases,  since  in  some  a  better 
view  can  be  obtained  by  grasping  the  tip  of  the  tongue  with  a  towel  or 
handkerchief  and   drawing  it  well  out  and  downward,  using  care  not  to 


UPPER  AIR-PASSAGES  AND  EAR.  237 

cause  pain  underneath  the  tongue  by  too  forceful  traction  over  the  lower 
teeth.  In  still  others  the  patient  may  be  able  voluntarily  to  depress 
the  tongue. 

The  oropharynx  is  examined  by  direct  inspection.  The  appearance 
and  color  of  the  mucous  membrane  of  the  posterior  pharyngeal  wall  vary 
greatly  according  to  the  condition  of  the  gastro-intestinal  tract.  The 
redness  frequently  observed  along  the  anterior  borders  of  the  faucial 
tonsillar  pillars  in  gouty  or  lithaemic  individuals  is  a  sign  of  diagnostic 
importance.  This  may  vary  in  color  from  a  dark  pink  blush  to  a  purplish 
crimson,  and  may  be  regular  in  outline  or  occasionally  present  the  appear- 
ance of  petechial  spots,  particularly  on  the  uvula.  Another  phenomenon 
often  observed  is  indicative  of  either  acute  or  chronic  inflammatory  Eus- 
tachian or  middle-ear  involvement.  It  consists  of  a  prominence  or  bulging 
of  the  postpharyngeal  wall,  evidently  an  inflammatory  infiltrate,  just  back 
of  the  posterior  faucial  pillar  on  the  same  side  as  that  of  the  affected  ear. 

In  the  examination  of  the  laryngopharynx  the  laryngoscope  is  used. 
Observe  the  base  of  the  tongue  carefully  to  detect  the  presence  of  an 
enlarged  lingual  tonsil,  which  gives  rise  to  various  annoying  symptoms, 
most  prominent  of  which  is  the  constant  accumulation  of  mucus  about 
the  glottis  and  the  resulting  pharyngeal  tenesmus.  Occasionally  this 
mass  of  tonsillar  tissue  is  sufficient  to  press  the  epiglottis  downward  and 
thus  interfere  with  the  examination  of  the  larynx  proper. 

Foreign  Bodies.  —  The  most  frequent  locations  of  foreign  bodies, 
such  as  broken  bits  of  toothpicks  or  match-sticks,  fish-bones,  tooth-brush 
brist'es,  etc.,  in  the  laryngopharynx  are  the  glosso-epiglottidean  pouches 
at  the  base  of  the  tongue,  or  else  in  the  sinus  pyriformis  which  lies  partially 
posterior  to  and  on  either  side  of  the  glottis.  The  patient's  sensation  of 
locality  of  a  foreign  body  in  such  a  position  is  frequently  misleading;  for 
instance,  a  fish-bone  or  bristle  sticking  in  the  base  of  the  tongue  may 
give  the  sensation  of  being  farther  down  in  the  larynx,  or  perhaps  even 
in  the  nasopharynx. 

Examination. — A  strong,  well  focussed  light  is  essential,  and  whether 
the  patient  be  in  the  sitting  or  recumbent  position,  the  head  must  be  well 
extended  and  free  breathing  through  the  mouth  insisted  upon.  The  auto- 
scope,  an  instrument  devised  some  years  ago  for  the  purpose  of  making 
direct  inspection  of  the  larynx,  is  not  generally  employed  at  the  present 
time.  Proceeding  with  the  usual  method,  the  patient's  tongue  is  depressed, 
or  drawn  outward,  the  laryngoscope  is  carefully  introduced  into  the  upper 
laryngopharynx  in  a  manner  that  will  push  the  uvula  backward  out  of 
range  of  the  reflected  laryngeal  image.  The  best  angle  of  reflection  can 
be  determined  according  to  the  case  in  hand,  the  epiglottis,  owing  to  its 
variability  both  in  point  of  shape  and  position  in  different  individuals, 
being  the  principal  obstacle  to  a  clear  view  of  the  underlying  structures. 
This  difficulty,  however,  can  best  be  obviated  by  the  influence'  which  the 
effort  on  the  part  of  the  patient  to  produce  certain  vocal  tones  has  upon 
the  position  of  the  larynx.  Two  vocal  sounds  are  utilized;  first,  the  classic 
"ah."  during  the  intonation  of  which  the  larynx  is  in  the  most  natural 
relation  to  the  surrounding  structures  at  rest,  except  for  the  fact  that  the 
cords  are  approximated  or  in  the  position  of  phonation.     With  the  parts 


238  MEDICAL  DIAGNOSIS. 

in  this  position  there  will  be  reflected  in  the  laryngoscope  the  edge  of  the 
epiglottis  and  a  narrow  margin  of  its  underlying  surface,  the  arytenoids, 
and  the  posterior  half  of  each  vocal  cord,  which  appears  in  the  mirror  as 
the  inferior  half. 

The  same  relation  will  still  be  preserved  if  the  patient  now  be 
instructed  simply  to  breathe,  allowing  the  arytenoids  and  hence  the  cords 
to  swing  freely  open.  But  to  obtain  an  image  of  the  junction  of  the  cords 
at  the  anterior  ends,  appearing  superiorly  in  the  mirror,  the  effort  to  pro- 
duce the  vowel  tone  "e"  must  be  made.  This  will  so  elevate  the  larynx 
and  change  its  position  in  relation  to  the  epiglottis  and  other  structures 
as  to  expose  the  whole  length  of  the  cords  and  the  whole  inferior  surface 
of  the  epiglottis  in  one  view,  and  in  most  cases,  after  holding  the  tone  for 
a  few  seconds,  the  patient  may  breathe  freely  without  the  tongue  falling 
back  to  its  original  position.  A  good  plan  is  to  have  the  patient  hold  the 
note  for  a  moment,  followed  by  free  respiration,  and  repeat  the  process  as 
often  as  required  till  a  satisfactory  view  is  obtained  of  all  the  intralaryn- 
geal  structures.  During  respiration  the  anterior  wall  of  the  trachea  also 
may  be  seen,  in  some  cases  as  far  down  as  the  bifurcation,  though  to  be 
satisfactory  an  examination  of  the  lower  part  of  the  trachea  and  bronchial 
tubes  should  be  made  with  a  bronchoscope.  This  instrument  has  been 
perfected  in  recent  years  to  such  an  extent  as  to  be  of  great  value  in  the 
hands  of  a  skilful  operator  for  the  removal  of  foreign  bodies  or  for  the 
inspection  of  any  diseased  condition  of  the  lining  membrane.  If  during 
the  examination  the  patient  has  an  inclination  to  gag,  free  and  rapid 
respiration  ma}r  overcome  it;  should  the  tendency  persist,  however,  with- 
draw the  mirror  and  allow  the  throat  to  be  at  rest  for  a  short  time;  under 
no  condition  will  anything  be  gained  by  forcing  or  attempting  to  prolong 
an  examination  when  the  patient  coughs,  gags,  or  the  muscles  of  the  throat 
become  fatigued. 

The  larynx  is  subject  to  the  same  inflammatory  changes  which  may  take 
place  in  any  other  mucous  membrane,  and  likewise  to  any  local  infection. 
The  histologic  structure  of  the  submucous  tissue  seems  to  favor  rapid  and 
extensive  oedema  from  local  inflammations,  due  to  traumata,  scalds,  and  the 
inhalation  of  irritant  vapors;  from  infectious  processes  involving  adjacent 
structures,  as  diphtheria,  follicular  tonsillitis,  and  tuberculosis;  and  from 
circulatory  disturbances  such  as  may  arise  from  cardiac  or  renal  lesions. 

Chronic  hoarseness  not  amenable  to  treatment,  particularly  in  indi- 
viduals past  forty  years  of  age,  must  be  regarded  as  suspiciously  indica- 
tive of  malignancy  and  be  kept  constantly  under  observation  in  order 
that  should  such  a  condition  exist  it  may  be  detected  at  the  earliest  stage 
possible.  Sluggishness  in  the  movement  of  the  vocal  cord,  or  even  an 
apparent  paralysis  of  the  cord  on  the  affected  side,  has  been  observed 
not  infrequently  in  laryngeal  carcinoma  long  before  any  actual  tumor 
was  visible. 

Otoscopy. 

For  convenience  in  description  the  organ  of  hearing  is  usually  divided 
into  the  external,  middle,  and  internal  ear.  The  last  embraces  that  part 
of  the  petrous  portion  of  the  temporal  bone  in  which  the  terminal  fila- 


DESCRIPTION  OF  PLATE  III. 

1.  Laryngeal  image  during  respiration. 

2.  Laryngeal  image  during  phonation. 

3.  Laryngoscopy  picture  in  a  case  of  paralysis  of  the  right  recurrent  laryngeal  nerve. 

4.  Laryngoscopy  picture  in  a  case  of  bilateral  paralysis  of  the  recurrent  laryngeal  nerves. 

5.  Laryngoscopic  picture  in  a  case  of  paralysis  of  the  interarytenoid  muscle. 

6.  Position  of  the  vocal  cords  in  unilateral  adductor  paralysis. 

7.  Position  of  the  vocal  cords  in  bilateral  adductor  paralysis— during  efforts  at  deep  inspiration. 

8.  Position  of  the  vocal  cords  in  paralysis  of  the  right  internal  tensor. 


PLATE  111. 


tftf 


v-ij^ir^ 


UPPER  AIR-PASSAGES  AND  EAR.  239 

merits  of  the  auditory  nerve  are  distributed,  and  therefore  is  also  desig- 
nated as  the  sound-perceiving  apparatus.  The  external  and  middle  ear, 
since  they  serve  the  purpose  of  transmitting  sound  impressions  to  the 
nerve,  are  called  the  sound-conducting  apparatus. 

It  is  of  importance  to  distinguish  between  diseased  conditions  of  the 
sound-perceiving  and  the  sound-conducting  apparatus,  or  between  disturb- 
ance of  hearing  caused  by  nerve  lesions  and  that  dependent  upon  diseased 
structures  of  the  ear  itself.  For  example,  in  any  case  of  deafness  the  first 
thing  to  be  ascertained  is  what  part  of  the  ear,  if  any,  is  at  fault.  Deaf- 
ness, either  partial  or  complete,  may  be  caused  by  obstructions  in  the 
external  auditory  canal,  such  as  foreign  bodies,  impacted  cerumen,  con- 
genital atresia,  exostosis,  furunculosis,  etc.,  and  also  by  hemorrhage  into 
the  semicircular  canals,  or  as  the  effect  of  certain  drugs.  The  condition 
of  the  external  canal  and  the  tympanic  membrane  can  easily  be  determined 
by  direct  ocular  inspection,  a  strong,  well  focussed  light  being  directed 
into  the  canal  through  a  suitable  speculum.  If  the  canal  be  found 
clear,  then  the  difficulty  must  lie  either  in  the  middle  or  the  internal  ear. 
To  distinguish  between  these  the  tuning-fork  test,  devised  by  Weber,  is 
usually  employed. 

External  Auditory  Canal. — The  external  auditory  canal  varies  greatly 
in  size  and  somewhat  in  direction  in  different  individuals.  The  cartilagi- 
nous portion  of  the  canal  is  usually  directed  more  or  less  downward  and 
forward,  so  that  in  order  to  bring  this  part  of  the  canal  and  the  bony  meatus 
into  the  same  axis  for  inspection  of  the  walls  of  the  canal  and  the  drum 
membrane  it  is  necessary  to  draw  the  auricle  gently  upward  and  backward. 
By  holding  the  auricle  in  this  position  with  one  hand  and  manipulating 
the  speculum  with  the  other — a  metallic  conical  speculum  is  the  most 
desirable — every  part  of  the  canal  wall  and  drum  membrane  may  be  clearly 
seen.  Note  the  size  of  the  canal  and  any  acute  inflammatory  swelling  or 
chronic  induration.  The  cartilaginous  portion  of  the  canal  comprises  a 
little  over  one-third  of  the  whole  length  of  the  meatus.  Its  junction  with 
the  bony  meatus  is  the  most  frequent  site  of  furunculosis.  In  young  chil- 
dren the  cartilaginous  meatus  comprises  about  two-thirds  of  the  whole 
extent  of  the  canal.  When  a  furuncle  is  of  deep  origin  pus  may  burrow 
beneath  the  periosteum  inward  toward  the  tympanic  cavity,  occluding 
the  osseous  meatus  entirely  and  giving  rise  to  most  excruciating  pain.  The 
pain  within  the  ear  and  swelling  extending  even  back  of  the  auricle  may 
be  confused  with  acute  mastoiditis.  In  furunculosis  the  most  acute  pain 
is  apt  to  be  elicited  by  pressing  upon  the  tragus,  or,  if  there  be  postauricular 
tenderness,  it  will  likely  be  superficial;  in  mastoiditis,  however,  the  pain 
may  be  slight  superficially  and  intensified  by  deep  pressure  over  the  mas- 
toid, and  pain  is  not  apt  to  be  elicited  on  pressure  over  the  tragus. 

When  the  cartilaginous  portion  of  the  canal  is  occluded  by  swelling, 
gently  insert  a  tightly  rolled  pledget  of  cotton  dipped  in  a  solution  com- 
posed of  camphor  and  carbolic  acid,  equal  parts,  and  allow  it  to  remain  a 
few  minutes.  The  swelling  is  thus  sufficiently  reduced  to  allow  the  intro- 
duction of  a  small  speculum  for  the  examination  of  the  deeper  canal  and 
tympanic  membrane.  This  solution  also  produces  partial  anaesthesia  of 
the  membrane,  thus  allowing  a  more  thorough  examination. 


240  MEDICAL  DIAGNOSIS. 

The  tympanic  membrane  separating  the  external  canal  from  the 
tympanum,  irregularly  oval  in  shape  and  slightly  concave  in  its  normal 
state,  is  affected  to  some  degree  by  every  inflammatory  disease  of  the  mid- 
dle ear,  both  acute  and  chronic,  and  should  therefore  receive  most  careful 
attention  in  every  aural  examination.  A  strong,  well  focussed  light  is  a 
necessity  and  the  largest  speculum  which  the  canal  will  admit  should  be 
used.  The  external  layer  of  the  drum  membrane  is  modified  skin,  clear 
and  almost  translucent  in  its  normal  condition,  and  through  it  can  be  seen 
the  impression  of  the  malleus  with  which  it  lies  in  direct  contact.  Acute 
inflammations  of  the  middle  ear  produce  a  pink  or  reddish  hue  along  the 
margins  of  the  malleus  and  in  some  cases  over  the  entire  membrane. 

Exudates,  serous  or  purulent,  in  the  tympanic  cavity,  even  though 
small  in  quantity,  produce  bulging  of  the  membrane  and  frequently  ter- 
minate in  spontaneous  rupture  into  the  external  canal.  In  acute  and 
chronic  inflammations  causing  occlusion  of  the  Eustachian  tube  the  tym- 
panic membrane  will  be  found  retracted.  Retraction  may  also  be  brought 
about  by  adhesions  within  the  tympanic  cavity  following  marked  inflam- 
matory involvement.  In  a  case  of  retracted  membrane  we  can  ascertain 
whether  the  tube  is  patulous  by  one  of  the  usual  methods  of  inflation. 
Valsalva's  consists  of  a  vigorous  expiratory  effort  while  the  nose  and 
mouth  are  kept  closed.  Politzer  inflates  the  tympanum  through  one  nos- 
tril by  compression  of  a  rubber  air-bag  while  the  patient  is  in  the  act  of 
swallowing.  The  opposite  nostril  and  the  mouth  are  closed.  Eustachian 
catheterization  is  the  most  satisfactory  method  in  difficult  cases.  With 
Siegel's  otoscope  the  air  within  the  external  auditory  canal  can  be 
exhausted  and  adhesions  involving  the  tympanic  membrane  observed. 
Aural  polypi  originate  most  frequently  within  the  middle  ear  from  gran- 
ular or  necrotic  tissue  and  protrude  into  the  external  canal  through  per- 
forations in  the  tympanic  membrane,  though  they  occasionally  may  be 
found  in  any  part  of  the  canal,  particularly  at  the  cartilaginous  and  osseous 
junction.  Exostoses  occur  in  any  portion  of  the  osseous  canal,  particularly 
from  the  posterior  wall  and  from  the  osseous  and  cartilaginous  junction. 
In  chronic  non-suppurative  processes  involving  the  middle  ear,  the  drum 
membrane  becomes  opaque  and  thickened,  and  usually  distorted  in  shape. 
In  cases  of  otosclerosis  white  chalky  spots  are  observed  in  the  membrane 
which  may  otherwise  appear  normal.  A  sign  of  diagnostic  importance 
in  mastoiditis  complicating  chronic  suppurations  of  the  middle  ear  is  an 
infiltration  of  the  membrane  covering  the  superior  posterior  osseous  wall 
of  the  external  auditory  canal,  presenting  the  appearance  of  a  circum- 
scribed drooping  or  bulging. 

Pharynx  and  Eustachian  Tube.  —  No  examination  of  the  ear  can  be 
considered  complete  without  a  careful  inspection  of  the  nasopharynx  at 
the  entrance  of  the  Eustachian  tube  slightly  below  and  anterior  to  the  fossa 
of  Rosenmuller.  The  technic  of  this  procedure  is  described  under  posterior 
rhinoscopy.  Catheterization  of  the  tube  for  diagnostic  purposes  can  be 
accomplished  either  through  the  nose  or  by  way  of  the  oropharynx. 


EXAMINATION  OF  THE  BLOOD.  241 

V. 
THE  EXAMINATION   OF   THE   BLOOD.1 

General  Considerations. —  Information  derived  from  blood  exami- 
nations, while  not  essential  in  the  establishment  of  a  diagnosis  in  most 
instances,  is  frequently  a  useful  aid.  Negative  blood  reports  are  often 
important  in  diagnosis,  as  in  the  exclusion  of  malaria  from  a  group  of  dis- 
eases which  have  similar  clinical  features,  such  as  malignant  endocarditis, 
septicaemia,  and  certain  types  of  tuberculosis.  Diseases  associated  with 
marked  splenic  or  glandular  enlargement  present  so  close  a  resemblance 
to  leukaemia  that  only  a  study  of  the  blood  can  exclude  the  latter 
condition.  Many  blood  examinations  elicit  results  which  assist  in  arriv- 
ing at  or  completing  a  diagnosis.  Evidence  of  a  pathognomonic  char- 
acter gained  from  haematological  studies  is  available  in  only  a  limited 
number  of  diseases,  notably  in  myelogenous  leukaemia,  malaria,  relapsing 
fever,  trypanosomiasis,  and  filariasis.  The  condition  of  the  blood  as  to 
haemoglobin  value,  the  number  of  erythrocytes  and  leucocytes,  may  serve 
as  an  index  of  body  nutrition.  Blood  counts  often  yield  information 
which  bears  upon  prognosis, — e.g.,  in  chlorosis  a  steady  haemoglobin 
rise  is  an  evidence  of  favorable  progress  of  the  patient,  while  an  erythro- 
cytic gain  in  progressive  pernicious  anaemia  or  leucocytic  decrease  in 
leukaemia  likewise  points  to  improvement.  Counts  of  the  white  corpuscles 
also  aid  in  establishing  the  leucocytic  standard  of  the  patient.  The  opsonic 
index  and  the  agglutination  phenomenon  are  recognized  adjuncts  in  the 
field  of  diagnosis. 

Methods   of   Blood    Examination. 

Obtaining  Blood.  —  For  most  clinical  examinations  a  few  drops  of 
blood,  obtained  from  a  puncture  in  the  lobe  of  the  ear  or  the  finger-tip, 
will  suffice.  The  lobe  of  the  ear  is  sometimes  selected  for  making  the 
puncture  on  account  of  its  lessened  sensibility  and  because  the  operation 
can  be  performed  without  the  patient  seeing  it,  but  the  finger-tip  is  generally 
chosen  as  this  site  is  more  convenient  for  the  examiner.  The  puncture 
should  be  made  with  a  lancet-shaped  or  triangular  surgical  needle,  an 
instrument  especially  devised  for  this  purpose,  or  a  steel  pen  with  one  of 
the  nibs  broken  off.  The  part  selected  should  be  cleansed  with  alcohol  or 
with  soap  and  water  followed  by  alcohol,  and  dried  with  a  towel  or  hand- 
kerchief. If  not  warm,  the  skin  is  wanned  by  gentle  friction,  but  forcible 
rubbing  should  be  avoided,  since  it  excites  active  hyperemia.  If  the 
individual  is  a  bleeder,  the  precaution  of  making  a  superficial  puncture 
and  of  having  measures  at  hand  to  control  hemorrhage  should  be  observe]. 
It  is  obvious  that  areas  of  oedema  and  of  inflammation  must  be  avoided. 
If  the  former  be  present  about  the  hands  or  ear,  an  area  free  or  nearly  so 
of  oedema  is  chosen.  The  puncture  is  made  with  a  quick  thrust  of  the 
instrument,  which  has  previously  been  cleansed  with  alcohol  or  passed 
through  a  flame.     The  first  drop  or  two  of  blood  should  be  wiped  away. 

1  Originally  contributed  by  Prof.  Kalteyer.     Revised  by  Dr.  Turner. 
16 


242 


MEDICAL  DIAGNOSIS. 


Forcible  squeezing  of  the  tissues  in  the  immediate  vicinity  of  the  wound 
must  be  avoided,  as  this  may  alter  the  composition  of  the  blood  by  the 
addition  of  lymph  fluids.  As  the  blood  flows  from  the  wound,  its  gross 
appearance  as  to  color  and  fluidity  is  noted. 


Fig.  92a. — Vacumm  syringes  for  collecting  blood  for  examinations. 

The  blood  may  be  drawn  from  a  vein  at  the  elbow  when  larger  quan- 
tities are  required  for  extensive  physical,  chemical,  and  biological  examina- 
A  tions.     A  tourniquet  or  bandage  is  ap- 

plied to  the  upper  arm  just  firmly  enough 
to  obstruct  the  venous  return  but  not  so 
tight  as  to  eliminate  the  arterial  pulse. 
Rj&e-r  The  tourniquet  is  often  removed  before 
Tv.hi-n£  the  blood  is  allowed  to  flow  in  order  to 
eliminate  any  alteration  caused  by  con- 
gestion. The  sterile  needle  of  a  syringe 
is  plunged  into  the  vein  after  the  part 
has  been  surgically  cleaned.  The  required 
quantity  is  thus  readily  obtained. 

Blaekfan  has  perfected  a  very  simple 
and  inexpensive  apparatus  for  use  in  col- 
lecting blood — from  infants  and  older 
patients — for  serological  examinations, 
although  not  of  value  in  obtaining  blood 
for  other  examinations  since  there  is  an 
admixture  of  tissue  fluids  with  the  blood. 
The  apparatus  is  connected  for  use.  The 
part  selected  is  usually  below  the  angle 
of  the  scapula.  A  small  puncture  is  made  in  the  sterilized  skin  in  one  or 
more  points  and  the  apparatus  immediately  applied.  The  necessary  amount 
is  easily  secured  without  the  use  of  much  suction.  "When  the  blood  has  been 
withdrawn  the  area  is  covered  with  a  sterile  dressing. 


Fig.  92b. — Suction  apparatus  for  collecting 
blood  for  the  Wassermann  Reaction.  A,  suction 
glass  connecting  at  B  with  suction  pump  C; 
the  blood  flows  through  D  connected  by  rub- 
ber stopper  with  an  ordinary  test  tube,  E. — 
Blaekfan. 


EXAMINATION  OF  THE  BLOOD.  243 

Preparation  of  Fresh  Blood  for  Immediate  Examination. — A  cover- 
glass  is  applied  to  a  droplet  of  blood  and  then  placed  upon  a  clean  slide. 
The  blood  usually  spreads  into  a  thin  layer.  Warming  the  slide  by  fric- 
tion with  a  piece  of  gauze,  a  handkerchief,  or  tissue  paper  before  applying 
the  cover-glass  facilitates  spreading.  In  a  well-prepared  preparation  the 
corpuscles  are  arranged  in  a  single  layer  separated  from  each  other  over 
an  area  sufficiently  large  for  the  desired  study.  If  it  be  necessary  to 
delay  the  examination,  drying  of  the  specimen  can  be  prevented  by  ring- 
ing the  margins  of  the  cover-glass  with  vaseline  or  cedar  oil. 

Preparation  of  Blood  for  Staining. — Cover-glasses  which  have  clean 
polished  surfaces  are  placed  upon  a  sheet  of  paper,  or  preferably  upon 
a  folded  towel,  from  which  they  can  be  picked  up  easily.  A  cover-glass, 
held  with  the  fingers,  or  with  forceps,  is  applied  to  the  summit  of  the 
droplet  of  blood,  being  careful  to  avoid  touching  the  skin,  and  allowed  to 
fall  upon  another  cover.  As  soon  as  the  blood  has  ceased  spreading,  the 
covers  are  slid  apart.  In  performing  this  operation,  care  should  be  exer- 
cised not  to  lift  the  glasses  apart:  the  sliding  motion  must  be  performed 
rapidly,  avoiding  a  jerky,  uneven  stroke.  The  smear  may  be  made  upon 
a  slide  by  placing  a  drop  of  blood  upon  it  and  spreading  with  another 
slide  or  with  a  glass  rod  especially  designed  for  this  purpose. 

Methods  of  Fixation. — Heat  Fixation. — The  covers  are  placed  in  an 
oven,  the  ordinary  dry-heat  sterilizer  being  convenient  for  this  purpose,  and 
heated  gradually  until  the  temperature  reaches  to  120°  C.  or  up  to  155°  C. 
and  subjected  to  this  temperature  for  from  ten  to  twenty  minutes.  A  con- 
venient plan  for  fixing  the  specimens  with  heat  consists  in  placing  the 
spreads  upon  a  heated  copper  plate.  The  plate,  about  20  centimetres  in 
length,' 8  centimetres  in  width,  and  from  y2  to  1  centimetre  in  thickness, 
supported  by  a  suitable  stand,  is  heated  at  one  end  with  the  flame  from  a 
Bnnsen  burner  or  an  alcohol  lamp.  "When  the  plate  is  thoroughly  heated, 
the  covers  are  placed  upon  it  at  a  point  where  the  temperature  is  sufficient 
to  boil  water  (which  is  previously  determined  by  dropping  water  upon 
its  surface,  beginning  at  the  end  farthest  away  from  the  flame)  and  exposed 
to  this*  heat  for  about  thirty  minutes.  A  method  less  suitable  than  the  ones 
mentioned  consists  in  passing  the  film  rapidly  through  a  Bunsen  flame 
forty  or  fifty  times. 

Fixation  by  Wet  Methods. — Fixation  may  be  obtained  by  submerg- 
ing films  in  a  mixture  of  equal  parts  of  absolute  alcohol  and  ether  for  twenty 
or  thirty  minutes,  or  in  absolute  alcohol  fur  five  minutes.  The  Futcher- 
La/.aer  method  subjects  the  films  to  .25  per  cent,  formalin  in  95  per  cent. 
alcohol  for  one  minute:  they  are  then  rinsed  in  water  and  dried  with 
filter-paper. 

Blood  Staining. — Many  methods  for  staining  blood  are  available.  To 
Ehrlich  belongs  the  credit  of  devising  a  mixture  by  which  all  known  varie- 
ties of  blood-cells  except  those  which  contain  basophilic  granules  are  com- 
pletely colored.  At  the  present  time  certain  panoptic  fluids  containing 
eosin-methylene-blue  compounds  are  employed  extensively  in  routine  work, 
having  largely  supplanted  Ehrlich's  triple  stain. 

Ehrlich's  triple  stain  is  prepared  by  mixing  saturated  aqueous  solu- 


244  MEDICAL  DIAGNOSIS. 

tions  of  acid  fuchsin  of  orange  G.  and  of  methyl  green  00  with  glycerin, 
ethyl  alcohol,  and  water. 

Staining  Technic. — The  stain  is  applied  to  the  blood-film  previously 
fixed  by  heat,  for  five  minutes,  after  which  the  excess  of  stain  is  drained 
off  and  the  cover  washed  with  water,  dried,,  and  mounted  in  xylol  balsam 
or  cedar  oil.  Normal  erythrocytes  are  colored  orange,  eosinophilic  granules 
dull  red,  neutrophilic  granules  violet  or  lilac,  nuclear  structures  various 
shades  of  green,  blue,  or  black,  malarial  parasites  and  bacteria  green  or 
blue,  while  basophilic  granules  are  unstained. 

Jenner's  stain  is  prepared  as  follows:  Mix  equal  parts  of  a  1  per 
cent,  aqueous  methylene-blue  solution  with  a  1.25  per  cent,  aqueous  eosin 
(water  soluble)  solution.  After  shaking  thoroughly,  the  solution  is  allowed 
to  stand  for  twenty-four  hours  and  then  filtered.  The  precipitate  is  dried. 
One  part  of  precipitate  is  dissolved  in  two  hundred  parts  of  methyl  alcohol. 
Films  are  treated  with  this  solution  without  previous  fixation  for  from 
three  to  five  minutes,  washed  with  water,  dried,  and  mounted  in  xylol 
balsam  or  cedar  oil.  The  following  tinctorial  reaction  is  secured:  Normal 
erythrocytes  stain  terra-cotta ;  nuclei,  various  shades  of  blue  or  green ; 
basophilic  granules,  dark  blue ;  neutrophilic  granules,  pink ;  eosinophilic 
granules,  bright  red ;  the  cytoplasm  of  lymphocytes  and  malarial  parasites, 
a  deep  blue.  A  deposit  of  dark  granules  upon  the  film  which  is  often  observed 
is  an  objectionable  feature  and  interferes  with  the  usefulness  of  this  method. 

Leishman's  stain,  an  improvement  on  Jenner's,  is  based  on  the 
Komanowsky  method.  It  is  prepared  as  follows:  (1)  A  one  per  cent,  aque- 
ous solution  of  methylene  blue  (Gruber's  medicinal),  containing  5  per  cent, 
of  sodium  carbonate,  is  heated  at  65°  C.  for  twelve  hours  and  then  allowed 
to  stand  for  ten  days.  (2)  An  equal  volume  of  a  1  per  cent,  solution  of 
eosin  in  distilled  water  is  added  to  the  methylene-blue  solution  in  an  open 
vessel  and  the  mixture  stirred  from  time  to  time.  After  twelve  hours  the 
resultant  sediment  is  collected  on  filter-paper  and  washed  with  water  until 
the  washings  are  almost  colorless.  One  and  a  half  parts  of  dried  powdered 
precipitate  are  added  to  one  hundred  parts  of  pure  methyl  alcohol.  Three 
or  four  drops  of  this  stain  are  placed  upon  the  unfixed  blood-film  and 
allowed  to  act  for  thirty  seconds,  when  double  the  amount  of  water  (six  or 
eight  drops)  is  poured  upon  the  cover  and  mixed  with  the  stain.  After  five 
minutes  the  spread  is  washed  gently  with  water  and  a  few  drops  allowed  to 
remain  upon  the  specimen  for  about  a  minute.  The  smear  is  now  dried, 
first  beween  filter-paper  and  then  in  the  air,  and  mounted  in  balsam  or  cedar 
oil.  The  nuclei  of  leucocytes  and  of  erythroblasts,  and  blood-platelets  are 
stained  various  shades  of  purple,  the  protoplasm  of  lymphocytes  and  certain 
polychromatophilic  erythrocytes  various  tints  of  blue,  basophilic  granules 
dark  violet  or  royal  purple,  normal  erythrocytes  and  eosinophile  granules 
pink,  and  neutrophile  granules  a  dull  red.  Malarial  parasites  and  try- 
panosomes  are  distinctly  stained  by  this  method. 

Wright's  stain  contains  an  eosin-methylene-blue  combination  held  in 
solution  by  methyl  alcohol.  The  unfixed  film  is  stained  for  one  minute, 
next  8-10  drops  of  distilled  water  are  added  to  film  stain  and  allowed  to 
stand  two  to  three  minutes.     The  film  is  stained  deep  blue.     It  is  now 


Fig.  93.— I.  leucocy- 
tometer:  II,  erythrocy- 
tometer  of  Thoma-Zeiss 
hsemoeytometer. 


C   » 




.a 

0  100  mm. 

*>-N. 

i 
4oo  cjmm. 

v® 

\c 

w? 

, 

B 


Fig.  94a. — Counting  chamber  of  the  Thoma-Zeiss 
haemoeytometer.  A,  profile  view;  B,  face  view;  a, 
wall  of  cell;  6,  central  disk'  c,  groove  about  disk;  d, 
ruled  surface 


45oSq.mm. 
jjjmm.deep 


PHILADELPHIA, 

c/.s>- 


Fig.  946. — Levy  counting  chamber  with  double 
Neubauer  ruling. 


_  III  II II  II 

l. 

= 

1 

s 

n 

1 

-|  ifliil? 

A  B 

Vic.  96a. — /I,  Zappert  ruling;   B,  Turk's  ruling. 


EXAMINATION  OF  THE  BLOOD.  245 

decolorized  by  washing  with  water  until  yellowish  or  pink.  Dry  between 
filter-paper  and  mount  in  balsam. 

End  Result.— Erythrocytes  orange  or  pink;  nuclei  of  leucocytes,  blue; 
neutrophile  granules,  lilac;  coarse  mast  cell  granules,  deep  purple.  The 
nuclei  of  erythroblasts  and  bacteria  stain  various  shades  of  blue;  blood 
plaques  purplish  flecked  with  red.  The  body  of  the  malarial  parasite  stains 
blue.     The  chromatin  varies  from  blue  to  red  to  almost  black. 

Double  Staining. — The  films,  after  suitable  fixation  obtained  by  immer- 
,sion  in  absolute  alcohol,  alcohol  and  ether,  or  by  heating  as  previously 
described,  are  treated  first  with  an  acid  stain  followed  by  a  basic  dye, 
rinsed  in  water,  dried,  and  mounted.  A  staining  fluid  containing  acid  and 
basic  coloring  principles  may  be  employed  for  this  purpose.  Most  of  the 
methods  of  double  staining  are  not  suitable  for  differentiating  all  forms 
of  blood-cells,  as  certain  histological  elements  remain  unstained.  Neu- 
trophilic granules  are  as  a  rule  not  colored,  and  therefore  neutrophilic 
myelocytes  cannot  be  distinguished  from  large  mononuclear  leucocytes. 

Plehivs  stain  has  the  following  formula: 

Saturated  aqueous  solution  of  methylene  blue 60  c.c. 

One-half  per  cent,  eosin  solution  (in  75  per  cent,  alcohol) 20  c.c. 

Distilled   water 40  c.c. 

Twenty  per  cent,  solution  of  caustic  potash 5-1  c.c. 

Specimens  are  fixed  in  absolute  alcohol  for  from  three  to  five  minutes, 
stained  with  Plehn's  solution,  washed  in  water,  dried,  and  mounted.  This 
mixture  stains  malarial  parasites  blue  and  eosinophilic  granules  red. 

Eosin  and  Methylene  Blue. — A  convenient  plan  consists  in  treating  the 
fixed  smear  w7ith  a  solution  consisting  of  eosin  .5  part  in  70  per  cent, 
alcohol  100  parts,  for  a  minute  or  two;  wash  the  cover  in  water,  and  then 
counterstain  with  a  half-saturated  solution  of  methylene  blue  or  Delafield's 
ha-matoxylin  solution  for  a  half  to  one  minute.  The  specimen  is  then 
rinsed  in  water,  dried  between  bibulous  paper  or  in  the  air,  and  mounted. 

Chrnzinsky  recoanmends  a  stain  composed  of  40  cubic  centimetres  of 
saturated  methylene  blue,  20  cubic  centimetres  of  a  .5  per  cent,  eosin  solu- 
tion in  70  per  cent,  alcohol  and  40  cubic  centimetres  of  distilled  water. 
Films  fixed  in  absolute  alcohol  are  subjected  to  Chenzinsky's  solution  for 
from  three  to  six  hours,  the  staining  being  done  at  37°  C.  in  an  incubator. 
Ehrlich  suggested  a  mixture  consisting  of  hematoxylin  2  grammes,  eosin  0.5 
gramme,  absolute  alcohol  100  grammes,  distilled  water  100  grammes,  glyc- 
erin 100  grammes,  acetic  acid  10  grammes,  and  an  excess  of  alum.  The  stain 
is  not  ready  for  use  until  several  weeks,  have1  elapsed,  since  this  time  is 
required  for  the  ripening  of  the  stain. 

Basophilic  granules  may  he  demonstrated  by  a  stain  recommended  by 
Ehrlich  which  has  the  following  formula  : 

Saturated   alcoholic   solution    of  dahlia 50  c.c. 

Acetic  acid   10-20  c.c. 

Distilled   water Kin  ,.  <. 

Differential  Counting. —  This  method  consists  of  determining  the  rela- 
tive number  of  the  different  forms  of  blood-cells,  generally  expressed  in 
percentage  figures  and  sometimes  as  the  number  per  cubic  millimetre.  The 
leucocyte  differential  estimation  is  important  in  the  diagnosis  of  a  number 


246 


MEDICAL  DIAGNOSIS. 


of  conditions.  An  approximate  differential  count  can  be  made  by  an 
examination  of  fresh,  unstained  blood  by  the  experienced  worker,  but  for 
accurate  determinations  stained  films  are  essential.  A  mechanical  stage  is 
necessary  for  this  method  of  counting. 

Technic. — The  specimen  is  brought  into  focus,  and  the  slide  is  shifted 
with  the  mechanical  stage  so  as  to  bring  successive  fields  into  view,  being 
careful  not  to  pass  over  any  portion  more  than  once.  The  different  forms 
of  leucocytes  are  noted  and  their  number  recorded  until  at  least  five  hun- 
dred cells  have  been  studied.  From  these  figures  the  relative  percentages 
are  calculated.  When  nucleated  erythrocytes  are  encountered,  their  num- 
ber should  also  be  noted,  and  the  total  number  of  these  cells  per  cubic 
millimetre  can  be  determined  by  the  following  formula : 


Number  of  leucocytes  per  cu.  mm.  X  number  of  nucleated 

red  cells  counted  in  the  stained  film 

Number  of  leucocytes  counted  in  the  stained  film 

It  is  sometimes  important  to  estimate  separately  the  different  varieties 
of  abnormal  red  cells,  especially  the  varieties  of  nucleated  cells. 


_  Number  of  nucleated  erythro- 
cytes per  cubic  millimetre. 


BBM  ■■■■  HRfl  1MB 


S! 

iSisiiisiii 

^■■■iiiSmi 


IBBBB 
IBBBB 
IBBBB 
!■■■■ 

■■■■I 

Ebbbb 
Ebbbb 

IBBBB 

E~~™~""         :::.  ~~*~^ 

Sbbbbihiiiiiii 

JBBBBIIIIIIilll 
IBBBflllllllllll 

IBBBBIIIIIIIIII 
IBBBBIIIIIIIIII 
WBBBIIIIillllll 

Fig.  956. — Neubauer  Ruling  for 
blood  counting. 


Fig.  95c. — Fuchs-Rosenthal  rul- 
ing for  spinal  fluids. 


Enumeration   of   the   Erythrocytes,   Leucocytes,   and   Blood=pIatelets. 

— For  clinical  purposes,  the  red  cells  are  counted  in  a  small  amount  of 
blood  of  known  quantity,  from  which  an  estimate  of  the  number  per  cubic 
millimetre  is  made,  this  figure  being  the  standard  upon  which  the  variations 
in  health  and  disease  are  based.  A  number  of  methods  are  available  for 
this  purpose.  The  one  recommended  by  Thoma  is  generally  selected,  as 
it  gives  fairly  accurate  results. 

The  Thoma=Zeiss  Hjemocytometer. —  This  apparatus  consists  of  two 
graduated  pipettes  (the  red  and  white  counters)  for  measuring,  diluting, 
and  mixing  the  blood,  and  a  glass  chamber  in  which  the  corpuscles  are 
counted.  The  erythrocytometer  consists  of  a  graduated  capillary  tube, 
upon  which  the  figures  .5  and  1  appear.  The  tube  expands  into  a  bulb, 
above  which  the  figure  101  is  inscribed.  A  rubber  tube  with  a  mouthpiece 
attached  is  fastened  to  the  short  end  of  the  pipette.  Filling  the  pipette 
with  blood  to  the  point  marked  .5  and  then  drawing  a  diluting  solution  into 
it  until  the  fluid  reaches  to  the  point  marked  101,  insures  a  blood  dilution  of 
1 :  200,  while  a  dilution  of  1 :  100  is  obtained  when  the  pipette  is  filled  to  the 
point  marked  1,  and  then  with  a  diluent  to  the  mark  101.  The  white 
pipette,  or  leucocytometer,  is  similar  in  construction  to  the  red  pipette,  but 
differs  in  that  the  capillary  bore  is  larger  and  the  bulb  smaller  so  that 
dilutions  of  1 :  20  and  1 :  10  may  be  secured. 


EXAMINATION  OF  THE  BLOOD.  247 

The  counting-  chamber  consists  of  a  heavy  glass  slide  upon  which  is 
cemented  a  glass  plate  having  a  circular  opening ;  a  disk  is  cemented  to  the 
slide  so  that  it  occupies  a  central  position  in  the  circular  opening  of  the 
plate.  The  disk  is  slightly  thinner  (by  one-tenth  of  a  mm.)  than  the  plate 
which  surrounds  it.  AYhen  the  cover-glass,  a  part  of  this  instrument,  is 
placed  upon  the  plate,  the  distance  between  the  disk  and  the  cover  is  one- 
tenth  mm.  The  surface  of  the  disk  is  ruled  by  vertical  and  horizontal  lines 
one-twentieth  of  a  mm.  apart.  These  lines  form  four  hundred  squares,  the 
dimensions  of  each  being  one-twentieth  by  one-twentieth  mm.  Groups  of  16 
squares  are  indicated  by  a  double  ruling.  The  space  overlying  each  square 
between  the  surface  of  the  disk  and  the  cover-glass  measures  yoVo  cu.  mm. 
(2V  mm.  X  -jV  mm.  X  tV  =  ToVc  cubic  millimetre).  Zappert's  modified  rul- 
ing cf  the  Thoma-Zeiss  counting  chamber  divides  the  surface  into  eight 
large  squares,  immediately  surrounding  the  400  small  squares:  each  large 
square  is  equal  to  the  surface  ruling  of  the  400  central  squares.  The  total 
ruling  represents  an  area  of  3600  small  squares. 

The  Levy  Counting  Chamber  is  said  to  possess  the  following  distinct 
characteristics: 

Increased  visibility  of  the  rulings  when  chamber  is  filled  with  solution. 

It  entirely  avoids  the  cemented  cell  and  the  attendant  danger  of  its 
loosening  by  the  drying  out  of  the  balsam  cement,  and  the  loosening  of  the 
ruled  counting  surface  is  also  greatly  reduced. 

The  parallel  form  of  cell  used  provides  a  more  uniform  distribution  of 
corpuscles  over  the  ruled  area  and  entirely  removes  the  effect  of  atmos- 
pheric pressure  upon  the  depth  of  the  solution,  a  source  of  considerable 
error  in  the  circular  form  chambers. 

The  parallel  form  of  cell  facilitates  cleaning  as  compared  with  the  cir- 
cular type. 

The  matte  finish  on  the  surface  of  the  slide  insures  better  approxima- 
tion between  the  under  surface -of  the  cover-glass  and  the  supporting  sur- 
face of  the  slide  than  when  two  polished  surfaces  are  used. 

Technic  of  Counting  the  Erythrocytes. — Special  fluids  are  employed 
for  diluting  the  blood.  Toisson'x  solution  stains  nuclei  a  pale  blue,  there- 
fore rendering  differentiation  between  non-nucleated  erythrocytes  and  white 
corpuscles  easy.     Its  composition  is  as  follows: 

Methyl  violet,  .",15 0.025  part 

Sodium  chloride 1.0     part 

Sodium  sulphate  H.O      parts 

Neutral  glycerin    .'50.0      parts 

Distilled  water 100.0      parts 

II mi  1  in  's  solution: 

Mercuric  chloride  0.25  part 

Sodium  chloride   0.5  part 

Sodium  Bulphate  2.5  parte 

Distilled  water    100.0  parts 

Other  diluting  fluids  recommended  for  clinical  work  are  a  2.5  per  cent, 
aqueous  solution  of  potassium  bichromate,  a  .5  per  cent,  aqueous  solution 
of  sodium  sulphate,  and  a  .7  per  cent,  aqueous  solution  of  sodium  chloride. 
Thase  solutions  should  be  filtered  before  using. 


248 


MEDICAL  DIAGNOSIS. 


The  blood  obtained  in  the  usual  manner  is  drawn  into  the  erythro- 
cytometer  to  the  point  .5,  unless  decided  oligocythemia  is  suspected,  when 
it  is  desirable  to  fill  to  the  mark  .1,  after  which  the  tip  of  the  pipette  is 
wiped.  Toisson's  or  some  other  diluting  solution  is  drawn  into  the  pipette 
until  the  fluid  reaches  to  the  point  101.  The  pipette  should  be  rotated 
gently  as  the  diluting  fluid  enters  the  bulb,  in  order  to  secure  a  mixture. 
After  filling  the  pipette,  the  thumb  and  finger  are  immediately  placed  over 
its  ends  and  the  instrument  shaken  for  about  a  half  minute,  in  order  to 
obtain  a  thorough  mixture.  The  unmixed  fluid  in  the  capillary  portion  is 
then  blown  out.  The  counting  chamber  is  now  placed  upon  a  perfectly 
level  surface  and  a  droplet  of  the  mixture  is  deposited  in  the  central  portion 
of  the  ruled  disk.  The  pipette  should  be  shaken  just  before  adjusting  the 
diluted  blood,  and  the  fluid  in  the  capillary  portion  should  always  be 
expelled  after  mixing  in  this  manner,  since  corpuscles  in  the  capillary  tube 

may  gravitate  on  standing,  thus  cre- 
ating an  uneven  mixture.  The  cover- 
glass  is  then  quickly  adjusted  in  its 
position.  If  the  fluid  flows  into  the 
depression  surrounding  the  disk,  the 
operation  must  be  repeated.  After 
the  corpuscles  have  settled,  the 
counting  chamber  is  placed  upon  the 
stage  of  the  microscope  and  a  field 
of  16  squares  is  brought  into  focus. 
In  general  routine  work,  the  calcu- 
lation of  determining  the  number  of 
erythrocytes  per  cubic  millimetre  is 
usually  based  on  the  number  of  cells 
found  within  61  squares,  provided  a 
uniform  distribution  of  the  cells 
exists.  The  following  plan  may  be 
adopted  in  counting  the  corpuscles: 
The  cells  within  the  upper  left-hand 
corner  square  of  a  group  of  16  squares  are  first  counted,  then  the  cells  in  each 
of  the  remaining  three  squares  in  that  line,  going  from  left  to  right,  after 
which  the  corpuscles  in  the  next  row  of  squares  are  enumerated,  proceeding 
from  right  to  left,  next  those  in  the  third  row  and  finally  in  the  last  line  of 
squares,  as  shown  in  the  diagram  (Fig.  96).  The  counting  chamber  is  now 
moved,  so  as  to  bring  into  focus  another  area  of  16  squares,  and  the  number 
of  cells  in  this  group  is  estimated.  This  process  is  repeated  until  the  desired 
number  of  squares  (not  less  than  64)  has  been  covered.  In  order  to  avoid 
confusion  in  counting,  the  corpuscles  which  touch  the  right  and  lower  lines 
are  included  in  the  count  of  the  square  in  question.  The  formula  for  calcu- 
lating the  number  per  cubic  millimetre  is  as  follows : 


— , 

A 

m 

B 

N | 

r 

J 

K 

\ 

-J 

A 

_ 

Fig. 


96. — Scheme  for  counting  cells  overlying  ruled 
surface. 


Number  of  cells  counted  X  4000  X  number  of  dilutions 


Number  of  cells  per  cubic  mm. 


Number  of  squares 

The  greater  the  number  of  cells  counted,  especially  with  low  dilutions, 
assuming  that  the  mixture  is  thorough,  the  more  accurate  will  be  the 
results. 


EXAMINATION  OF  THE  BLOOD.  249 

Technic  of  Counting  the  Leucocytes. — In  determining  the  number 
of  leucocytes,  the  red  pipette  may  be  used,  but  more  accurate  results  are 
obtained  with  the  white  pipette,  as  lower  dilutions  are  secured.  A  i/2  or  Vs 
per  cent,  aqueous  solution  of  acetic  acid  is  employed  when  using  the  white 
counter  in  order  to  dissolve  the  red  cells.  Except  in  the  case  of  leukemic 
blood,  a  dilution  of  1 :  20  or  1 :  10  is  most  convenient  for  the  majority  of 
leucocytic  counts.  "When  the  number  of  white  cells  is  estimated  with  the 
red  counter,  with  a  1 :  100  or  1 :  200  dilution,  Toisson's  solution  is  very  use- 
ful, since  with  it  the  leucocytes  are  tinted  blue  and  therefore  readily  dis- 
tinguished from  erythrocytes,  which  have  a  yellowish  or  greenish  color.  WTith 
Zappert's  modified  ruling  the  cells  overlying  a  larger  area  can  be  counted. 
The  formula  for  estimating  the  leucocytes  per  cubic  millimetre  is  the  same 
as  that  used  for  determining  the  number  of  erythrocytes.  In  routine  clini- 
cal work  the  corpuscles  overlying  the  entire  ruled  area  of  at  least  400  squares 
should  be  counted  when  employing  dilutions  of  one  in  ten  or  twenty. 

Cleansing  the  Instrument. — After  removing  the  fluid  from  the  pipette, 
it  is  rinsed  with  water,  then  with  alcohol,  and  finally  with  ether,  and  dried 
thoroughly.  An  atomizer  bulb  is  useful  for  expelling  the  fluid  from  the 
tube  and  for  drying.  A  simple  method  of  removing  the  fluid  from  the 
pipette  consists  in  pressing  the  end  of  the  rubber  tube  between  the  fingers 
so  as  to  occlude  its  lumen,  and  then  by  twisting  the  tube  the  fluid  is  expelled 
from  the  pipette.  The  counting  chamber  should  be  cleaned  with  water  and 
dried  with  a  soft  handkerchief  or  tissue  paper.  Alcohol,  ether,  and  xylol 
should  not  be  used  for  cleaning  the  counting  chamber,  since  these  substances 
may  dissolve  the  cement  which  holds  the  parts  together. 

Enumeration  of  Blood-platelets. — The  blood-platelets  are  rarely 
seen  in  fresh  unstained  specimens,  as  they  disappear  almost  immediately 
after  tbe  blood  is  exposed  to  the  air.  They  are  colorless,  spherical,  oval, 
or  irregular,  varying  considerably  in  size,  usually  from  one  to  three  microns. 
In  fresh  blood,  platelets  are  demonstrated  by  placing  a  cover-glass  upon 
a  slide  and  bringing  their  edges  in  contact  with  the  blood  as  it  flows  from 
the  puncture.  Their  number  may  be  approximately  estimated  by  Deter- 
man's  method  as  follows:  Place  a  drop  of  a  9  per  cent,  aqueous  solution 
of  sodium  chloride  upon  the  skin  and  make  the  puncture  through  the  drop 
of  fluid.  As  the  blood  flows  from  the  wound,  it  is  mixed  with  the  reagent  by 
stirring  with  a  cover-glass  or  slide,  and  then  a  part  of  this  mixture  is  placed 
upon  the  Thoma-Zeiss  counting  chamber  and  the  cover-glass  adjusted.  The 
ratio  of  blood-platelets  to  erythrocytes  is  next  determined  in  a  given  area. 
The  number  of  red  corpuscles  per  cubic  millimetre  is  found  by  the  Thoma- 
Zeiss  method,  and  from  this  figure  the  actual  number  of  blood-platelets  per 
cubic  millimel  re  can  be  calculated  by  the  ratio  the  red  cells  bear  to  platelets. 

Haemoglobin  Estimation. — The  principle  involved  in  the  estimation  of 
haemoglobin  with  most  of  the  instruments  used  in  clinical  work  is  based 
npoc  a  comparison  of  the  color  of  undiluted  or  diluted  blood  with  a  standard 
color  scale. 

Dare's  Method. — The  principle  of  this  method  is  based  on  matching 
the  tint  of  a  film  of  undiluted  blood  of  definite  thickness  with  a  graduated 
color  scale.  The  essential  parts  of  this  haemoglobinometer  are  a  wedge- 
shaped  semicircle  of  "lass  stained  with  Cassius's  "golden  purple"  so  thai. 
the  various  depths  of  the  color  displayed  by  the  scale,  represent  haemoglobin 


250 


MEDICAL  DIAGNOSIS. 


values  ranging  from  10  per  cent,  to  120  per  cent,  (this  wedge  is  contained 
within  a  hard-rubber  case  so  that  it  can  be  revolved  by  operating  a  thumb- 
screw); a  telescoping  camera  tube  supplied  with  a  magnifying  lens  through 
which  the  color  of  the  blood  and  that  of  a  part  of  the  wedge  is  viewed;  a 
pipette  composed  of  two  plates  of  glass,  one  being  transparent  and  the 
other  opaque  (white  glass);  a  part  of  the  surface  of  the  latter  is  slightly 
bevelled,  so  that  a  thin  compartment  is  formed  between  the  plates  when 
their  surfaces  are  opposed;  and  a  candle  holder. 

Technic.  —  The  pipette  is  brought  in  contact  with  a  large  drop  of 
blood.  It  fills  by  capillarity.  The  pipette  is  then  placed  in  its  compart- 
ment on  the  side  of  the  case.     The  light  of  a  candle  is  used  in  making 

the  color  comparison,  the  instru- 
ment being  held  in  a  position  so  as 
to  avoid  direct  sunlight.  The  rapid- 
ity with  which  an  accurate  haemo- 
globin estimation  can  be  made  is  the 
greatest  advantage  of  this  method. 
The  matching  of  the  colors  should 
be  done  immediately  after  filling  the 
pipette,  since  coagulation  may  begin 
within  three  or  four  minutes.  The 
tint  of  the  colored  wedge  of  Dare's 
haemoglobinometer  does  not  in  every 
instance  correspond  exactly  with  the 
color  curve  of  certain  anaemic  bloods. 
Tallqvist's  H.emoglobinom- 
eter. — With  this  method  the  color 
of  a  drop  of  blood  soaked  into  filter- 
paper  is  compared  with  a  color  scale 
lithographed  upon  jDaper.  The 
apparatus  consists  of  a  book  con- 
taining sheets  of  white  filter-paper 
and  a  lithographed  color  scale  of 
ten  tints  representing  haemoglobin 
values  between  10  and  100  per  cent. 
Technic. — A  piece  of- the  white  filter-paper  is  applied  to  the  drop  of 
blood,  and,  as  soon  as  the  moist  gloss  has  disappeared  from  the  surface  of 
the  blood-soaked  paper,  its  color  is  compared  with  the  scale.  Accurate 
results  are  not  claimed  for  this  simple  method.  An  error  of  at  least  ten 
per  cent,  is  unavoidable. 

Von  Fleischl  ELemometer.  —  This  instrument  is  composed  of  the 
following  parts:  A  metallic  stage  having  a  circular  opening  in  its  centre, 
supported  by  a  stand.  To  the  frame  of  this  stand  is  attached  a  plaster- 
of-Paris  reflector.  A  glass  wedge,  tinted  with  Cassius's  ''golden  purple," 
fixed  within  a  metal  frame.  The  depths  of  the  color  of  the  wedge  corre- 
spond to  a  scale  of  haemoglobin  percentages  stamped  upon  the  frame,  which 
range  from  1  to  120.  A  cylindrical  metallic  mixing  cell,  divided  into  equal 
parts  by  a  vertical  partition,  and  provided  with  a  glass  bottom.  A  capil- 
lary measuring  pipette  attached  to  a  metal  handle.     As  the  capacity  of  the 


2  1 

Fig.  97. — 1.  Dare's  hspmoglobinometer.  A, 
telescope  ;  B,  pipette  in  place  ;  C,  case  enclosing 
color-prism ;  D,  milled  head  moving  prism ;  E, 
candle;  F,  window  admitting  light  to  color-prism. 
2.  Pipette.  A,  the  white  glass;  B,  clear  glass 
disk. — Emerson. 


EXAMINATION  OF  THE  BLOOD. 


251 


pipettes  varies  in  different  instruments,  a  figure  is  stamped  upon  the  handle 
of  the  pipette  and  a  similar  marking  on  the  stage  of  the  instrument  for  which 
it  is  suited.     A  finely  pointed  glass  dropper,  for  filling  the  metallic  cell. 

Technic. — When  one  end  of  the  pipette  is  brought  in  contact  with 
the  blood,  secured  in  the  usual  manner,  it  fills  automatically  by  capil- 
larity. Blood  adhering  to  the  external  surface  of  the  pipette  must  be 
wiped  away  before  emptying  its  contents.  After  partially  filling  one 
of  the  compartments  of  the  cell  with  water,  the  blood  is  washed  out 
of  the  pipette  with  water.  The  blood  and  the  water  are  then  thoroughly 
mixed  by  stirring  with  the  handle  of  the  pipette.  The  fluid  adhering 
to  the  handle  must  then  be  washed  off  with  water,  which  is  allowed  to 
drain  into  the  mixing  compartment.  The  other  division  of  the  cell  is 
filled  with  water.  Avoid  moistening  the  top  of  the  vertical  septum,  as 
this  may  cause  the  fluids  of  the  compartments  to  commingle.  The  filled 
cell  is  now  adjusted  in  its  proper  position  on  the  stage,  and  a  comparison 
of  the  color  of  the  diluted  blood  with  that  of  the  scale  is  made  in  a  dark- 
ened room,  or  with  a  light-proof  box.  A  candle  flame  placed  about  15 
or  20  centimetres  in  front  of  the  plaster-of-Paris  reflector  is  used  for  illu- 
mination. The  operator,  standing  to  one  side  of  the  instrument,  matches 
the  colors  by  turning  the  thumb-screw.  The  glass  wedge  should  be  moved 
quickly.  Never  view  the  colors  for  more  than  a  few  seconds,  since  the 
eye  is  easily  fatigued  by  prolonged  inspection.  After  two  readings  have 
been  made,  the  mean  of  these  is  taken  as  the  result.  An  attempt  should 
always  be  made  to  compare  only  the  median  portion  of  the  color  fields, 
which  may  be  readily  accomplished  3 

by  placing  under  the  glass  bottom  of 
the  cell  a  diaphragm  of  thin  metal 
or  paper,  having  a  narrow  slit  about 
4  millimetres  in  width,  the  long 
axis  of  which  is  at  right  angles 
to  the  partition  of  the  mixing  cell. 

AY  hen  the  haemoglobin  percent- 
age is  low  (below  30).  two  or  three 
pipettes  full  of  blood  should  be  used, 
and  the  result  divided  by  the 
number  of  pipettes  employed. 
Degree  of  error  with  the  von  Fleischl 
instrument  is  between  5  and  10 
per  cent. 

The  Meischer's  H.^moglo- 
BINOMETER. — This  modification  of 
the  von  Fleischl  instrument  pos- 
sesses certain  advantages  over  the 
latter  whereby  the  degree  of  error  is 
considerably  lessened.  The  prin- 
ciple of  Meischer's  method  is  the 
same  as  that  of  von  Fleischl.  A 
mixing  pipette  is  employed  with  which  accurate  dilutions  of  1 :200,  1:300,  or 
1 :40()  can  be  secured.     For  normal  blood  or  Dearly  so,  dilutions  of  1:400  are 


Fir,.  OS. — I.  Meischer's  modification  ofFleiscbl'a 
hsmoglobinometer.  A,  stage;  £,  color-prism  rack; 
(',  milled  head  ;  D,  cell ;  /•.',  cover-glass  ;  F,  cap  ;  <:, 
cell  seen  from  :ili"\<-.  -'.  Mixing  pipette.  3.  Colur- 
pri>m. — Eniersou. 


252  MEDICAL  DIAGNOSIS. 

most  convenient,  but  with  low  haemoglobin  values  dilutions  of  1 :  200  or  1 :  300 
are  more  serviceable.  Two  metallic  chambers  are  employed,  each  of  which 
is  divided  by  a  vertical  partition  and  supplied  with  a  glass  bottom.  One 
compartment  receives  the  diluted  blood,  the  other  water.  One  chamber 
is  shallower  than  the  other.  The  partition  dividing  the  cells  is  slightly 
raised  so  that  the  glass  cover,  provided  with  a  groove,  may  be  slid  over 
the  top  of  the  cylinder,  thereby  preventing  the  fluids  from  commingling. 
A  lid  having  a  narrow  oblong  opening  is  used  to  cover  the  chamber  so 
that  the  width  of  the  field  exposed  when  making  the  color  comparison 
does  not  correspond  to  more  than  three  degrees  of  the  percentage  scale. 
The  tinted  wedge  of  this  instrument  is  more  accurate  than  that  of  the 
von  Fleischl.  After  securing  the  desired  dilution  and  mixture  in  the 
pipette,  one  of  the  compartments  in  each  of  the  cells  is  filled  with  the 
blood  solution,  the  other  compartment  with  water:  the  glass  cover  is 
then  slid  into  position  and  the  metal  top  adjusted.  The  reading  of  each 
cell  is  then  made  with  artificial  illumination,  using  the  same  technic  as 
with  the  original  von  Fleischl  method.  The  result  of  the  reading  of  the 
shallower  cell  is  multiplied  by  f ;  this  figure  should  correspond  closely  with 
the  reading  of  the  other  chamber,  one  result  controlling  the  other.  The 
mean  of  the  two  readings  represents  the  haemoglobin  percentage. 

Oliver's  H.emoglobinometer. — With  this  method  the  color  of  a 
definite  quantity  of  diluted  blood  is  compared  with  a  standard  color  scale, 
consisting  of  a  series  of  tinted  glass  plates.  The  instrument  is  composed 
of  the  following  parts:  A  standard  blood  scale  composed  of  12  colored 
disks,  mounted  upon  a  perfectly  white  surface  in  two  metal  frames.  Their 
tints  correspond  with  the  color  of  various  dilutions  of  blood.  These  primary 
disks  correspond  to  haemoglobin  percentages  ranging  from  10  to  120; 
two  pieces  of  tinted  glass,  called  riders,  are  supplied  with  the  instrument 
for  ordinary  clinical  purposes.  When  a  rider  is  superimposed  upon  a  pri- 
mary color,  its  shade  deepens  and  therefore  determines  intermediate 
percentages  between  those  indicated  by  the  disks.  An  error  of  2\  per 
cent,  is  unavoidable.  A  capillary  tube  having  a  capacity  of  5  cubic 
millimetres  for  measuring  blood.  A  standard  mixing  cell  provided  with  a 
glass  lid.  A  camera  tube  through  which  the  colors  are  viewed,  and  a 
pipette  for  washing  the  blood  out  of  the  measuring  pipette. 

Technic.  —  The  blood  measured  in  the  pipette  is  washed  into  the 
mixing  cell  with  water  and  mixed  with  the  handle  of  the  pipette.  The  fluid 
wnich  adheres  to  the  handle  is  rinsed  with  the  water  and  the  cell  filled. 
The  glass  lid  of  the  mixing  cell  is  then  adjusted  in  a  manner  so  that  a 
small  air  bubble  is  present  under  the  cover.  The  color  of  the  diluted  blood 
is  matched  with  one  of  the  disks  of  the  color  scale  in  a  darkened  room, 
illuminated  with  the  light  of  a  small  wax  candle  placed  about  10  centi- 
metres in  front  of  the  mixing  cell  and  the  color  disk.  One  or  both  riders 
may  be  required  to  intensify  the  tint  of  the  primary  disk. 

Gowers's  H^moglobinometer. — With  this  method  a  definite  quan- 
tity of  blood  is  diluted,  until  the  color  of  the  mixture  corresponds  with 
a  standard  color  contained  in  a  tube.  This  instrument  consists  of:  A 
standard  color  tube  which  contains  glycerin  jelly  colored  with  picrocar- 
mine,  so  that  its  tint  corresponds  with  that  of  a  solution  containing  one 


EXAMINATION  OF  THE  BLOOD. 


253 


part  of  normal  blood  in  a  hundred  parts  of  water;  a  mixing  test-tube 
having  a  graduated  scale  ranging  from  5  to  120;  a  pipette  for  measuring 
20  cubic  millimetres  of  blood. 

Technic. — The  measuring  pipette,  to  which  is  attached  a  small  rubber 
tube,  is  filled  by  suction  up  to  the  point  marked  20.  A  few  drops  of 
water  are  placed  into  the  mixing  tube,  then  the  blood  in  the  pipette  is 
blown  into  the  tube.  'Water  is  added  in  small  amounts,  shaking  after 
each  addition  in  order  to  secure  a  mixture,  until  the  color  of  the  solution 
corresponds  with  that  of  the  standard  tube.  The  height  of  the  fluid 
reached  indicates  the  haemoglobin  percentage.  The  color  comparison  is 
made  with  daylight  by  holding  the  tube  against  a  white  background. 

Sahli's  H.kmometer. —  The  principle  of  this  method  is  based  on 
comparing  the  tint  of  a  standard  fluid 
composed  of  a  definite  amount  of  normal 
blood  and  of  a  decinormal  solution  of 
hydrochloric  acid  with  the  tint  of  a  solu- 
tion of  blood  to  be  tested  treated  with  a 
decinormal  hydrochloric  acid  solution  and 
water  in  sufficient  quantity  to  exactly 
match  the  colors.  The  height  of  the 
column  of  fluid  in  the  mixing  tube  indi- 
cates the  haemoglobin  percentage.  Sahli 
claims  that  with  this  method  the  color 
of  the  standard  solutions  and  that  of  the 
blood  properh'  diluted  corresponds  quite 
accurately,  thereby  insuring  uniform 
results.  The  apparatus  is  similar  in  con- 
struction to  Gowers's  haemometer.  It 
consists  of  a  sealed  tube  containing  the 
standard  color  solution  of  decinormal 
hydrochloric  acid  holding  one  per  cent,  of 
blood;  a  graduated  test-tube  for  mixing 

the  blood  with  a  decinormal  hydrochloric  acid  solution  and  water;  a 
pipette  for  measuring  20  cubic  millimetres  of  blood;  a  perforated  stand 
with  a  white  glass  back  for  holding  the  tubes;  a  bottle  for  carrying  the 
acid  solution;  and  a  finely  pointed  pipette.  The  standard  color  fluid 
has  a  brownish-yellow  color,  due  to  hamiatin  hydrochlorate  held  in  sus- 
pension. Since  precipitation  of  this  substance  will  occur  on  standing, 
the  sealed  tube  is  provided  with  a  glass  ball  which  serves  to  mix  the  parti- 
cles when  the  tube  is  agitated. 

Technic. — The  graduated  tube  is  filled  with  decinormal  hydrochloric 
acid  to  the  mark  10.  Twenty  e.mm.  of  blood  measured  in  the  pipette 
are  then  blown  into  the  acid  solution  and  mixed.  The  measuring  pipette 
i-  then  filled  with  water  and  discharged  into  the  mixing  tube.  The 
graduated  tube  is  now  placed  in  its  compartment  in  the  stand  alongside 
of  the  standard  tube  and  water  is  added  in  small  amounts  to  the  blood 
solution,  mixing  after  each  addition,  until  the  color  matches  tic  standard 
tint.    The  height  of  the  column  of  fluid  in  the  tube,   as  indicated  by  the 


Fig.  99. — a,  Sahli's  lisemometer ;  b,  pipette. 


254  MEDICAL  DIAGNOSIS. 

graduated  scale,  represents  the  haemoglobin  percentage.  The  test  is  con- 
ducted with  natural  or  artificial  light.  More  accurate  readings  are  possible 
when  the  test  is  made  with  artificial  light  in  a  darkened  room. 

Color  (ndex.— The  terms  color  index,  blood  decimal,  or  blood  quotient 
are  used  to  express  the  average  haemoglobin  richness  of  the  erythrocytes. 
This  factor  is  determined  by  dividing  the  haemoglobin  percentage  by  the 
percentage  of  colored  corpuscles  per  cubic  millimetre.  The  normal  color 
index  is  expressed  by  the  figure  1,  i.e.,  100  per  cent,  of  haemoglobin  divided 
by  100  per  cent,  of  red  cells.  In  anaemic  states  the  same  result  is  ob- 
tained when  the  haemoglobin  and  red  cells  are  proportionately  reduced. 
In  chlorosis  the  color  index  is  generally  decidedly  diminished,  while  in 
most  symptomatic  anaemias  it  is  slightly  and  in  some  cases  markedly  low- 
ered. In  pernicious  anaemia,  except  during  periods  of  improvement,  it 
is  generally  increased. 

Estimation  of  the  Relative  Volume  of  Plasma  and  of  Corpuscles. — 
This  determination  is  made  by  applying  centrifugal  force  to  blood  con- 
tained in  a  tube,  which  separates  the  corpuscles  from  the  plasma.  By 
estimating  the  volume  of  corpuscles,  an  approximate  idea  may  be  formed 
of  the  number  of  cells  per  cubic  millimetre. 

Daland's  Hematocrit.- — This  instrument  consists  of  a  set  of  gears 
operating  a  metal  frame  into  which  are  fastened  two  capillary  tubes. 
A  hand  lever  is  connected  with  the  gears.  The  tubes  for  measuring  the 
blood,  graduated  into  100  equal  divisions,  are  50  millimetres  in  length, 
with  a  lumen  of  £  millimetre  diameter. 

Technic. — A  piece  of  rubber  tubing  with  a  mouth-piece  is  attached 
to  one  end  of  the  graduated  tube.  Blood  is  sucked  into  the  pipette 
until  completely  filled.  After  removing  the  rubber  tubing,  the  pipettes 
containing  blood  are  fastened  into  the  metal  frame  and  immediately  the 
handle  of  the  instrument  is  turned  for  3  minutes,  at  the  rate  of  about 
77  revolutions  per  minute,  which  produces  the  speed  desired.  The 
centrifugal  force  separates  the  blood  into  three  layers;  the  one  most 
distant,  of  dark  red  color,  is  composed  of  erythrocytes,  the  middle  one, 
of  milky  color,  is  formed  of  leucocytes,  while  the  inner  clear  layer  con- 
sists of  plasma.  With  normal  blood  the  column  of  erythrocytes  reaches 
to  the  graduation  marked  50  or  51;  each  division  of  the  scale  approx- 
imately represents  100,000  corpuscles  per  cubic  millimetre.  Accurate 
estimations  of  the  number  of  cells  per  cubic  millimetre  is  impossible,  since 
the  size  of  the  erythrocytes  varies  in  pathological  conditions  and  because 
a  uniform  speed  is  almost  impossible  to  obtain.  Variations  in  the  cen- 
trifugal force  will  produce  differences  in  the  degree  of  compactness  of  the 
cells.  The  number  of  leucocytes  can  only  be  roughly  estimated  when 
there  is  a  marked  increase,  as  in  leukaemia,  but  under  normal  conditions 
or  pathological  states  with  slight  or  moderate  variations  the  leucocytic 
layer  is  too  indistinct  to'warrant  an  opinion  as  to  their  number.  The 
pipettes  of  this  instrument  should  be  cleaned  immediately  after  using  by 
passing  a  fine  wire  through  the  lumen,  then  washing  with  water,  followed 
by  alcohol  and  ether. 

Volume  Index. — Volume  index,  the  term  applied  to  represent  the 
average  volume  of  the  erythrocyte,  is  determined  by  dividing  the  per- 


EXAMINATION  OF  THE  BLOOD.  255 

centage  volume,  as  estimated  with  the  haematocrit,  by  the  percentage  of 
the  erythrocytes  per  cubic  millimetre,  obtained  with  the  haemocytometer. 

Estimation  of  Specific  Gravity. — An  accurate  estimation  of  the 
specific  gravity  of  the  blood  can  be  obtained  by  Schmaltz's  method,  which 
consists  of  weighing  a  dry  pipette  upon  a  sensitive  balance.  The  pipette 
is  then  filled  with  water  and  the  weight  determined.  After  cleaning  and 
drying,  the  pipette  is  filled  with  blood  and  again  weighed.  From  these 
figures  the  specific  gravity  is  calculated. 

Hammerschlag's  Method.  —  Hammerschlag's  modification  of  Roy's 
method  is  based  upon  the  principle  of  suspending  a  drop  of  blood  in  a 
liquid  having  the  same  specific  gravity.  The  specific  gravity  of  the  sus- 
pension fluid  is  then  determined  with  a  hydrometer,  which  corresponds 
to  that  of  the  blood. 

Technic. — Pour  benzol  and  chloroform  into  an  hydrometer  jar,  in 
such  proportions  as  to  secure  a  mixture  having  a  specific  gravity  of 
about  1.060.  Partially  fill  a  pipette,  or  medicine  dropper,  with  blood 
and  insert  it  into  the  benzol-chloroform  solution;  expel  a  droplet  into 
the  fluid.  If  the  blood  is  lighter  than  the  mixture,  it  will  rise  to  the 
top.  Benzol  should  then  be  added  and  the  fluid  carefully  stirred  with  a 
glass  rod  until  the  blood  is  suspended  in  the  mixture.  The  specific  grav- 
ity of  the  benzol-chloroform  solution  is  next  determined,  which  corre- 
sponds to  that  of  the  blood.  If  the  specific  gravity  of  the  blood  is  greater 
than  that  of  the  benzol-chloroform  mixture,  causing  the  blood  to  sink, 
the  addition  of  chloroform  is  necessary  to  cause  suspension.  This  method 
of  determining  the  specific  gravity  is  seldom  employed  in  clinical  work, 
as  it  is  tedious  and  as  errors  of  technic  are  readily  made.  The  specific 
gravity  ranges  of  the  blood  correspond  quite  closely  to  definite  haemoglobin 
percentages;  notable  exceptions  to  this  rule  are  found  in  progressive  per- 
nicious anaemia,  where  the  haemoglobin  percentage  is  slightly  higher  than 
the  specific  gravity  indicates,  while  in  leukaemia  the  reverse  is  observed. 
Hammerschlag's  scale  of  specific  gravity  ranges  with  equivalent  haemoglobin 
percentages  is  as  follow-: 

Spec.  Gravity.  Ihrmoglobin. 

1.033-1.035 25-30  per  cent. 

1.035-  1.038 30-35  per  cent. 

1.038   1.040 35-40  per  cent. 

1.040   1.01.". 40-45  per  cent. 

1.045  1 .0 1 8 15-55  per  cent. 

1.048-1.050 55-65  per  cent . 

1.050   1 .053 65-70  per  cent. 

1 .053   1  .055 70-75  per  cent. 

1.055  1 .057 75  85  per  cent. 

1.057-1.060 85-95  per  cent. 

Estimation  of  the  Time  of  Coagulation. — As  a  number  of  condi- 
tions influence  the  rapidity  with  which  coagulation  of  the  blood  occurs 
after  it  is  withdrawn  from  the  blood-vessels,  such  as  the  amount  of  blond 
and  the  temperature,  the  results  obtained  by  different  methods  of  deter- 
mining the  clotting  time  are  not   available  for  comparative  studies.     In 

this  connection  it  should  also  be  borne  in  mind  that  the  factors  which 
control  intra-  and  extravascular  coagulation  are  in  all  likelihood  dissimilar. 


256 


MEDICAL  DIAGNOSIS. 


Method  of  Russell  and  .Brodie. — The  coagulation  time  is  deter- 
mined by  microscopical  study  of  the  blood.  The  apparatus  needed  for 
this  method  is  provided  with  a  moist  chamber  having  a  glass  bottom.  A 
removable  glass  cone  (the  lower  surface  of  which  is  4  mm.  in  diameter) 
forms  the  upper  portion  of  the  chamber.  A  current  of  air  is  introduced 
into  the  chamber  by  means  of  a  small  tube  one  end  of  which  projects  into 
the  cell,  while  to  the  other  end  is  attached  a  rubber  tube  supplied  with  a 
bulb.  Boggs's  coagulometer,  a  modification  of  the  instrument  just  de- 
scribed, is  equipped  with  an  improved  glass  cone  and  a  metal  tube. 

Technic. — A  drop  of  blood  is  placed  upon  the  lower  surface  of  the 
cone  which  is  then  immediately  fitted  into  the  chamber.  The  instrument 
is  then  put  upon  the  stage  of  the  microscope  and  with  a  low-power  objec- 
tive the  blood  is  brought  into  focus.  At  successive  intervals  the  blood  is 
agitated  by  means  of  the  current  of  air  sent  into  the  cell  from  the  bulb. 
It  will  be  noted  that  at  first  the  stream  of  air  causes  the  corpuscles  to 


D  E 


Fig.  101.- 


Diagram  to  illustrate  the   movement   of  the 
cells  during  coagulation. — Emerson. 


Fig.  100. — Coagulometer  of  Russell  and 
Brodie  as  modified  by  Boggs.  A,  moist  cham- 
ber ;  B,  cone  of  glass,  the  lower  surface  of  which 
holds  the  drop  of  blood  ;  C,  side  tube  ;  D  and 
E,  cover-glass  ;  at  E,  a  pinhole. — Emerson. 

move  freely.  A  little  later  clumps 
form  in  the  peripheral  zone  of 
the  blood  and  these  can  be  ad- 
vanced by  the  air  current.  Then 
as  clotting  progresses  masses  of 
blood-cells  cease  to  move  freely,  the  drop  alters  its  shape,  and  the  cor- 
puscles exhibit  a  concentric  motion.  Lastly,  a  radial  movement  appears, 
clumps  of  cells  being  displaced  by  the  air  current  towards  the  centre  and 
these  quickly  return  to  their  original  position.  Clotting  is  now  considered 
complete.  The  normal  coagulation  time  as  determined  by  this  method  varies 
from  three  to  eight  minutes,  the  average  time  being  about  five  minutes. 

Wright's  Method. — The  coagulometer  devised  by  Wright  consists 
of  a  cylindrical  tin  vessel  provided  with  a  perforated  partition,  the  open- 
ings of  which  are  so  arranged  as  to  support  twelve  graduated  tubes  and 
a  thermometer.  The  tubes  are  graduated  for  5  c.c.  of  blood,  and  are  num- 
bered from  one  to  twelve. 

Technic. — Water  having  a  temperature  of  18.5°  C.  is  poured  into 
the  metal  container.  The  blunt  end  of  six  or  eight  of  the  tubes 
is  then  covered  with  a  rubber  cap.  The  tubes  are  then  placed,  closed 
end  downward,  into  the  water.  After  having  acquired  the  tempera- 
ture of  the  water,  they  are  removed  separately  at  once  or  one-half 
minute  intervals,  the  cap  taken  off,  filled  with  5  c.c.  of  blood  and  imme- 
diately replaced   into  the  water  without  reapplying  the  caps.     Attempts 


EXAMINATION  OF  THE  BLOOD  257 

at  short  intervals  are  made  to  dislodge  the  blood  from  the  tubes  by  blow- 
ing. When  the  blood  cannot  be  removed  from  one  of  the  tubes,  coagula- 
tion may  be  considered  complete.  The  clotting  time  is  the  difference  of 
time  between  the  filling  the  tube  and  the  unsuccessful  attempt  to  expel 
its  contents.  With  this  instrument  the  coagulation  time  of  normal  blood 
in  most  instances  is  from  three  to  six  minutes,  although  the  period  may 
be  as  long  as  fifteen  minutes. 

Bacteriological  Examination. — There  are  two  methods  of  demonstrat- 
ing bacteria  in  the  blood — one  by  an  immediate  miscroscopical  examination 
of  stained  films,  the  other  by  blood  culturing.  The  former  plan  is  applicable 
only  in  a  limited  number  of  diseases  and  cannot  be  employed  as  a  routine 
procedure  because  the  blood  obtained  by  puncturing  the  skin  frequently  be- 
comes contaminated  with  bacteria  which  are  normally  present  in  the  skin, 
especially  the  staphylococcus  epidermidis  albus.  However,  this  method  has 
been  found  convenient  in  the  diagnosis  of  very  severe  cases  of  bubonic  plague. 
Films  can  be  prepared  by  placing  several  large  drops  of  blood  upon  a  slide  so 
as  to  secure  a  thick  spread.  Before  staining,  much  of  the  hemoglobin  may  be 
removed  from  the  dried  film  by  soaking  the  specimen  in  distilled  water.  Far 
more  reliable  results  are  obtained  by  removing  5-10  c.c.  of  blood  from  a  vein 
and  diluting  it  with  100  c.c.  of  bouillon.  From  this  mixture  the  bacterio- 
logical investigations  are  then  made.  In  the  late  stages  of  anthrax  infection 
the  blood  may  show  a  large  number  of  bacilli  so  that  the  immediate  micro- 
scopical method  may  give  positive  results.  In  this  disease  the  cultural  method 
gives  more  certain  results  than  the  study  of  films  prepared  from  blood 
obtained  by  puncture  of  the  skin. 

Technic. — The  skin  of  the  flexor  surface  of  the  elbow  is  cleansed 
as  for  a  surgical  operation,  by  scrubbing  thoroughly  with  soap  and 
water,  washing  with  sterilized  water,  alcohol,  and  ether,  after  which  an 
antiseptic  dressing  is  applied  and  allowed  to  remain  for  six  or  eight 
hours.  The  operator,  having  prepared  his  hands,  should,  after  removing 
the  antiseptic  dressing,  wash  the  skin  with  sterilized  water.  A  syringe 
(of  moderate  size  like  the  instrument  used  for  exploratory  puncture) 
or  a  special  "blood  aspirator"  is  required  to  remove  the  blood  from 
the  vein.  A  most  useful  instrument  employed  by  many  workers  con- 
sists of  a  graduated  glass  tube  having  a  capacity  of  about  10  cubic 
centimetres,  one  end  of  which  is  fitted  to  a  No.  42  hypodermic  needle, 
and  into  the  other  end  a  small  plug  of  cotton  is  inserted.  In  order 
to  sterilize  the  instrument,  it  is  placed  in  a  large  glass  tube,  the  ends  of 
which  are  then  plugged  with  cotton.  After  sterilization  a  piece  of  rubber 
tubing  is  fastened  to  the  end  of  the  aspirator  containing  the  cotton.  A 
bandage  is  wound  around  the  arm  of  the  patient  so  as  to  obstruct  the 
venous  circulation,  and  when  the  superficial  veins  at  the  elbow  become 
distended,  the  needle  of  the  syringe  or  blood  aspirator  is  inserted  into 
the  most  prominent  vessel.  The  piston  is  withdrawn  slowly  until  the  desired 
quantity  of  blood  is  obtained.  As  a  rule  the  blood  flows  freely  into  the  aspi- 
rator previously  described,  but,  should  this  not  be  the  case,  a  sufficient  amount 
can  be  secured  by  making  suction  through  the  rubber  tube. 

17 


258 


MEDICAL  DIAGNOSIS. 


The  blood  is  placed  in  a  suitable  culture  medium.  Fluid  media  such  as 
bouillon  and  litmus  milk  are  generally  selected  for  the  primary  inocula- 
tions when  certain  types  of  bacteria  are  suspected,  while  agar  may  be 
chosen  when  the  medium  is  to  be  plated.  One  or  two  cubic  centimetres 
of  blood  are  added  to  50  or  100  c.c.  of  fluid  medium  so  that  dilutions  of 
one  in  fifty  or  one  in  one  hundred  are  secured.  For  details  of 
bacteriological  technic,  which  do  not  fall  within  the  scope  of  this 
work,  special  treatises  on  bacteriology  should  be  consulted. 

Agglutination  Reaction. — The  blood  in  certain  stages  of 
typhoid  fever,  and  often  after  the  attack,  possesses  the  prop- 
erty of  checking  the  motility  of  typhoid  bacilli  and  causing 
these  organisms  to  form  into  clumps.  This  agglutination 
phenomenon  is  so  pronounced  that  high  dilutions  of  blood, 
as  one  in  fifty  or  one  hundred,  or  even  higher,  give  positive 
results.  The  blood  in  similar  dilutions  in  other  diseases  and 
in  health  does  not  act  in  this  manner  with  typhoid  bacilli. 
With  low  dilutions,  however,  a  positive  agglutination  reaction 
is  often  present  with  normal  or  abnormal  blood.  In  a  number 
of  diseases — as  pneumococcal  and  streptococcal  infections, 
paratyphoid  fever,  Malta  fever,  tuberculosis,  cholera,  plague, 
relapsing  fever,  glanders,  and  others — specific  agglutination 
reactions  have  been  obtained.  The  agglutination  test  is 
chiefly  employed  in  the  diagnosis  of  typhoid  and  paratyphoid 
fevers  and  is  generally  spoken  of  as  the  Widal,  Gruber-Widal, 
or  Pfeiffer- Widal  reaction.  For  this  test  two  methods  are 
available,  (1)  the  microscopic  and  (2)  the  macroscopic.  In 
typhoid  fever  the  agglutination  reaction  is  positive  in  about 
97  per  cent,  of  the  cases  during  the  course  of  the  disease, 
manifesting  itself  in  a  majority  of  them  about  the  end  of  the 
first  or  during  the  second  week,  in  a  few  instances  as  early 
as  the  third  or  fourth  day,  while  in  others  it  is  not  obtained 
until  the  attack  is  far  advanced,  and  it  often  persists  long 
after  convalescence.  The  intensity  of  the  reaction  varies  in 
different  cases.  Positive  reactions  are  obtained  with  dilu- 
tions as  high  as  1:200.  In  some  instances  the  reactions  occur 
almost  instantly,  while  in  others  the  stoppage  of  motility 
and  clumping  take  place  slowly. 

1.  Microscopical  Serum  Test.  —  This    test    may    be    per- 
formed with  fluid  blood,  blood-serum,  or  dried  blood. 

Technic. — Preparing  Cultures. — From  a  slant  agar  growth 
of  typhoid  bacilli,  preferably  not  older  than  one  month,  sub- 
cultures are  made  in  sterile  bouillon  and  incubated  at  blood 
heat  for  8  to  12  hours,  when  they  are  ready  for  use.  The  stock  culture 
should  be  kept  in  a  cool  place.  Some  workers  prefer  a  suspension  of 
typhoid  bacilli  in  salt  solution  made  by  placing  a  loopful  of  a  twenty-four 
hour  agar  growth  in  saline  solution.  The  tube  containing  the  fluid  is 
agitated  until  a  uniform  suspension  of  the  germs  is  obtained. 

Collecting  and  Diluting  Serum.  —  A    capillary    pipette,   suitable    for 
measuring  the  blood,  is  made  from  a  piece  of  glass  tubing  about  30  cm. 


Fig.  102.— 
Capillary 
pipette. 


EXAMINATION  OF  THE  BLOOD. 


259 


in  length  and  5  or  6  mm.  in  diameter.  The  middle  portion  of  this  tube 
is  heated  in  the  Bunsen  flame,  rotating  continuously  in  its  long  axis  until 
the  glass  is  thoroughly  softened  over  3  to  6  centimetres  of  its  length; 
remove  from  the  flame  and  draw  the  two  ends  apart  with  a  steady  uniform 
pull  so  that  the  heated  portion  tapers  into  a  long  capillary  tube.  By 
melting  the  middle  of  the  capillary  tube  in  the  flame,  two  pipettes 
with  the  capillary  end  sealed  off  are  made.  A  Wright's  blood  capsule, 
shown  in  Fig.  103,  will  be  found  convenient  for  collecting  the  blood. 
Preparing  the  Serum. — The  patient's  finger-tip  is  cleansed  and 
rubbed  briskly  so  as  to  produce  hyperemia.  A  puncture  is  then  made 
of  sufficient  size  so  as  to  insure  a  good  flow  of  blood.  The  sealed  tips 
of  a  Wright's  capsule  are  broken  off,  and  the  end  of  the  short  curved 
portion  of  the  capsule  is  placed  into  the  blood  as  it  issues  from  the 
small  wound,  the  body  of  the  tube  slanting  downward  so  as  to  allow 
the  blood  to  enter  by  gravity.  The  capsule  is  partly  filled  (h  or  % 
full).  The  tip  of  the  longer  arm  is  sealed  off  by  heating  in  a  flame. 
When  properly  cooled,  the  blood  is  shaken  down.  The  other  end 
may  then  be  closed  to  prevent  evaporation,  if  the  test  is  not  made 
immediately.  The  capsule  is  now  hooked  upon  the  rim  of 
a  centrifuge  tube  and  centrifugahzed  until  clear  serum  sepa- 
rates. Slight  turbidity  of  the  serum  does  not  interfere  with 
the  test.  The  capsule  containing  the  centrifugahzed  blood  is 
opened  by  filing  a  groove  into  the  glass  tube  above  the  level 
of  the  serum  and  breaking  off  the  end.  The  fine  end  of  a 
capillary  pipette  (having  previously  been  broken  off  the  sealed 
tip)  is  inserted  into  the  capsule  and  the  serum  drawn  into  the  tube.  The 
blood -serum  may  be  diluted  and  mixed  with  the  culture  in  watch  crystals 
or  in  a  porcelain  plate  having  a  number  of  cup-shaped  depressions  as  shown 
in  Fig.  104.  One  drop  of  serum  is  now  placed  into  one  of  the  depressions 
of  the  porcelain  plate.  Dilutions  of  the  serum  with  sterilized  normal 
salt  solution  are  then  made.  The  capillary  tube,  having  been  cleaned 
with    suit    solution  or  water,  is  partly  filled   with  saline   fluid.     Into   the 

depressions  containing  a  drop  of 
serum,  24  drops  of  salt  solution  are 
allowed  to  fall  from  the  pipette  and 
mixed,  thus  making  a  dilution  of 
1-25,  since  the  drops  from  the 
pipette  are  practically  of  the  same 
size.  Into  a  second  depression  are 
placed  5  drops  of  salt  solution 
and  5  drops  of  the  diluted  serum 
lution.  More  accurate  results  are  obtained 
the  serum  in  a  Thoma-Zeiss  hsemoevtometer 


Fig.  103.— 
Tube  for  serum 
work. — Emerson. 


Fig. 


104.— Porcelain    'lisk    for    mixing    serum,   Bait 
solution,    anil    bacterial    cultures. 


of 
by 


1-25,  securing  a   1-50   ( 

measuring  and  diluting  t lie  serum  in 
pipette.  Two  hanging  drop  preparations  arc  prepared — one  from  each 
dilution — by  mixing  upon  a  cover-glass  a  platinum  loopful  of  bouillon 
culture  of  typhoid  bacilli  with  a  loopful  of  diluted  scrum.  Since  each 
dilution  of  serum  is  again  diluted  to  ', ,  the  proportions  now  stand 
I  50  and  1  100.  The  rover-glasses  are  adjusted  upon  the  slides  and  the 
edges  of  the  slips  surrounded  by  petrolatum  to  prevent  evaporation.     The 


260  MEDICAL  DIAGNOSIS. 

preparations  are  allowed  to  stand  at  room  temperature  for  exactly  one 
hour.  In  order  to  secure  correct  results,  it  is  essential  that  the  motility 
of  the  bacilli  should  be  active,  and  the  density  of  the  culture  be  uniform 
and  not  show  clump-like  gatherings. 

Recording  Results. — At  the  end  of  one  hour,  the  hanging  drop  slides 
are  examined  microscopically.  When  motion  of  the  bacilli  is  found  absent 
and  clumping  good  in  both  slides,  the  reaction  is  termed  "positive,"  but 
when  the  free  motion  without  clumping  of  bacteria  is  noted,  the  test  is 
negative.  Variations  between  these  two  extremes  may  be  recorded  ac- 
cording to  the  judgment  of  the  examiner.  Thus,  if  1-50  shows  no  motion 
and  good  clumping,  but  1-100  exhibits  slight  motion  and  only  fair  clump- 
ing, the  reaction  may  be  called  "very  suggestive;"  or,  again,  if  1-50 
shows  slight  motion  and  poor  clumping,  while  1-100  free  motion  and  no 


sr' 


W'^Mf^W     MS 


- 


I  ^     w  - 


■ .  . 


Fig.  105.  —  Widal   test.     Field   of  motile   organ-        Fig.    106.  —  Widal    test.     Field    of    agglutinated 
isms. — Emerson.  organisms. — Emerson. 

clumping,  the  reaction   may  be  called  "slightly  suggestive."      It  is  best 
to  indicate  definitely  the  results  of  each  dilution,   as  for  example: 

1-50    Good  clumping.  No  motion. 

1-100  Fair  clumping.  Slight  motion. 

This  allows  the  diagnostician  to  form  his  own  conclusions  and  does 
away  with  dogmatic  assertions,  such  as  "Widal  positive"  or  "Widal 
negative,"  which  are  so  often  a  matter  of  personal  equation  upon  the 
part  of  the  laboratory  worker. 

The  liquid  serum  method,  unfortunately,  cannot  always  be  employed 
by  physicians  in  active  practice.  The  microscopical  test  may  be  carried 
out  with  blood  collected  upon  a  piece  of  paper,  or  upon  a  slide  and  allowed 
to  dry,  after  which  the  test  may  be  made  at  any  time.  The  blood  secured 
in  this  manner  is  moistened  and  dissolved  in  sterilized  water,  and  then  diluted 
and  mixed  with  the  culture  in  the  desired  proportions.  It  is  obvious  that 
accurate  dilutions  are  impossible,  an  objection  to  this  method. 

2.  Macroscopical  Serum  Test.  —  By  aspirating  a  vein,  a  sufficient 
amount  of  blood  is  collected  in  a  sterile  test-tube  and  allowed  to  clot, 
so  as  to  separate  the  serum,  or  the  blood  may  be  centrifu gated.     The 


EXAMINATION  OF  THE  BLOOD.  261 

serum  is  mixed  with  salt  solution  and  bacterial  culture  in  the  desired  pro- 
portions (1-50  or  1-100).  In  the  case  of  a  positive  reaction  a  flaky  precipi- 
tate will  separate  with  a  clear  supernatant  fluid,  while  a  negative  reaction 
shows  uniform  turbidity  of  the  fluid.  The  macroscopical  test  may  also 
be  performed  by  mixing  bouillon  and  serum  in  proper  dilutions  and  inocu- 
lating the  mixture  with  a  loopful  of  a  broth  culture.  The  presence  of  a  pre- 
cipitate in  the  tube  at  the  end  of  twenty-four  hours'  incubation  signifies 
a  positive  result.  The  chief  objection  to  the  macroscopic  method  is  the 
relatively  large  amount  of  blood  required.  The  microscopic  test  is  gen- 
erally employed  in  clinical  work.  The  macroscopical  test  may  also  be 
performed  with  dead  cultures  of  the  bacilli.  The  principle  of  the  Ficker 
"Typhus  Diagnosticum"  is  based  on  mixing  a  dead  culture  with  diluted 
blood-serum.  Bacilli  in  liquid  media  killed  with  carbolic  acid  or  formalin 
are  also  employed  for  this  test. 

Opsonic  Index  of  the  Blood  and  Its  Determination. —  Leishman 
in  1902  devised  a  method  for  estimating  the  phagocytic  activity  of  the 
leucocytes.  Extensive  researches  upon  this  subject  have  recently  been 
made  by  Wright  and  Douglas,  and  many  other  investigators.  Opsonins 
are  substances  within  the  blood  which  prepare  bacteria  for  ingestion  by 
the  white  cells.  The  power  of  the  leucocytes  alone  to  ingest  bacteria,  the 
so-called  "spontaneous"  phagocytosis,  has  been  shown  to  be  very  slight, 
and  the  role  played  by  them  in  fighting  diseases  is  merely  as  scavenger, 
collecting  bacteria  acted  upon  by  the  opsonins.  Opsonins  do  not  stim- 
ulate or  otherwise  affect  the  leucocytes.  These  substances  are  destroyed 
by  a  temperature  of  65°  C.  for  ten  minutes. 

Technic.  —  The  special  technic  used  for  the  determination  of  the 
opsonic  power  of  the  blood  may  be  briefly  set  forth  as  follows:  There 
must  be  on  hand  for  the  test  (1)  an  emulsion  of  the  bacteria  in  salt  solution, 
(2)  washed  white  blood-cells,  taken  from  any  source,  (3)  serum  from  the 
patient's  blood,  and  (4)  serum  of  normal  blood  or  from  a  mixture  of  healthy 
bloods  taken  as  a  standard  control. 

Preparing  the  Bacterial  Emulsion. — The  micro-organisms  for  the  test 
are  inoculated  upon  culture  medium.  For  some  forms  of  bacteria,  as  the 
Staphylococcus  aureus,  an  agar  medium  is  selected.  After  twenty-four 
hours  of  incubation  at  37°  C.  a  fair-sized  colony,  found  on  the  culture 
medium,  is  removed  and  mixed  with  a  sterile  .85  per  cent,  salt  solution. 
The  resulting  bacterial  emulsion  is  drawn  up  and  down  in  a  small  pipette 
by  means  of  rubber  teat.  The  emulsion  is  set  aside  for  a  few  minutes  so 
as  to  allow  the  bacterial  clumps  to  settle.  The  supernatant  liquid  is  then 
removed  and  diluted  to  the  desired  density.  Centrifugalizing  may  be  neces- 
sary to  separate  bacterial  clumps.  With  bacteria  not  readily  emulsified, 
such  as  tubercle  bacilli,  grinding  between  glass  plates  or  in  an  agate  mortar 
is  required  to  disintegrate  1  lie  masses.  The  emulsion  in  case  of  tubercle 
bacilli  may  be  made  from  fresh  cultures  or  from  dry,  dead  germs,  such  as 
are  obtained  in  the  production  of  tuberculin.  Tubercle  bacilli  are  besl 
emulsified  with  a  1.5  per  cent,  salt  solution.  The  proper  density  is  one 
which  on  mixture  with  a  normal  serum  and  with  the  leucocytes  in  equal 
proportions  will  show  thai  after  incubation  an  average  of  5  or  6  germs 
have  been  phagocytozed  by  each  leucocyte.     The  density  of  the  standard 


262  MEDICAL  DIAGNOSIS. 

bacterial  mixture  may  be  fixed  by  McFarland's  nephelometer,  or  by  count- 
ing the  bacteria  in  a  given  amount  of  emulsion  in  a  Thoma-Zeiss  count- 
ing chamber. 

Obtaining  the  Washed  Leucocytes. — A  test-tube  is  filled  two-thirds  full 
with  an  aqueous  solution  containing  1.5  per  cent,  sodium  citrate  and  .85  per 
cent,  sodium  chloride.  The  finger  is  pricked  and  S  to  12  drops  of  blood 
are  allowed  to  fall  into  the  tube.  The  solution  is  shaken  and  then  the 
tube  is  placed  in  an  electric  centrifuge  and  centrifugalized  for  5  minutes 
at  a  speed  of  1500  to  2000  revolutions  per  minute.  The  citrate  defibrin- 
ates  the  blood  and  prevents  clotting,  while  the  sodium  chloride  solution 
washes  the  cells  free  of  serum.  Upon  removal  from  the  centrifuge,  the 
tube  is  found  to  contain  a  compact  sediment  of  blood-cells  with  a  clear 
or  very  slightly  cloudy  supernatant  fluid  which  consists  of  serum  and 
salt  solution.  Overlying  the  surface  of  the  red  sediment  will  be  found 
a  white  coating  termed  the  "creamy  layer,"  which  is  formed  principally 
of  white  cells.  The  clear  supernatant  fluid  is  now  drawn  off  with  a  capil- 
lary pipette  by  means  of  a  rubber  bulb.  The  layer  of  leucocytes,  which 
contains  some  red  cells,  is  now  carefully  removed  from  the  compact  layer 
of  erythrocytes  with  the  capillary  pipette  and  placed  in  a  small  glass 
tube  having  a  sealed  end.  The  leucocytes  may  be  washed  with  saline 
solution  several  times  in  order  to  remove  the  sodium  citrate.  This  is 
accomplished  by  placing  the  leucocytes  in  a  centrifuge  tube  or  small  test- 
tube  and  partly  filling  it  with  .85  per  cent,  salt  solution.  The  tube  is 
then  centrifugalized,  after  which  the  supernatant  fluid  is  removed  with  a 
pipette.     This  operation  may  be  repeated. 

Obtaining  the  Serum. — A  Wright's  capsule  is  filled  two-thirds  full  of 
blood,  obtained  from  the  patient,  and  centrifugalized  until  the  serum  is 
clear.  Serum  must  also  be  obtained  from  normal  blood.  Having  on  hand 
the  bacterial  emulsion,  washed  corpuscles,  and  serum,  the  main  part  of 
the  test  may  be  carried  out.  By  means  of  a  capillary  pipette,  equal 
amounts  of  bacterial  emulsion,  white  blood-cells,  and  serum  are  measured, 
and  the  fluid  mixed  on  a  slide  or  watch  crystal  by  drawing  the  material 
up  and  forcing  it  down  the  capillary  pipette.  The  fluids  are  measured 
in  the  following  manner:  The  rubber  teat  attached  to  the  pipette  is 
compressed,  and,  by  gently  relaxing  the  pressure,  white  cells,  bacterial 
emulsion,  and  serum,  in  the  order  named,  are  drawn  into  the  capillary 
bore  up  to  the  mark  indicated  by  the  pencil  mark,  each  column  being 
separated,  by  a  small  air  bubble.  Two  pipettes  are  necessary  for  one  test, 
one  for  the  patient's  serum,  the  other  for  the  control  serum.  A  special 
pipette,  supplied  with  a  rubber  teat,  is  often  used  to  measure  and  mix 
the  bacterial  emulsion  serum  and  washed  leucocytes,  and  is  constructed  in 
such  a  manner  as  to  allow  the  worker  a  means  of  controlling  accurately 
the  amount  of  fluids  drawn  up  in  the  long  arm  of  the  pipette  and  of 
mixing  the  contents  afterwards.  The  sealed  tip  of  a  capillary  pipette 
having  been  broken  off  squarely,  a  pencil  mark  is  made  2  or  3  cm.  above 
its  extremity.  After  the  ingredients  are  thoroughly  mixed,  the  fluid  is 
drawn  into  the  pipette  and  its  end  sealed  in  the  flame.  The  tube  is  then 
placed  in  the  incubator  at  37°  C.  for  15  minutes.  In  a  like  manner,  the 
control  test  is  prepared  with  equal  amounts  of  white  corpuscles,  bacterial 


EXAMINATION  OF  THE  BLOOD.  263 

emulsion,  and  normal  serum,  which  are  also  incubated.  After  incubation 
the  end  of  the  pipette  is  broken  off  and  the  contents  are  run  up  and  down 
so  as  to  mix  thoroughly.  Smear  preparations  are  made  of  the  material 
from  each  pipette  upon  slides  or  cover-glasses.  After  fixation  the  smears 
are  treated  with  any  reliable  stain,  such  as  Leishman's,  which  brings  out 
distinctly  the  leucocytes  and  bacteria.  For  tubercle  bacilli,  carbol  fuchsin 
and  Gabbett's  or  Pappenheim's  stain  may  be  employed.  The  specimens 
are  now  examined  with  an  oil-immersion  lens.  The  number  of  bacteria 
in  100  typical  polymorphonuclear  neutrophiles  is  determined  in  both  speci- 
mens. The  average  number  of  bacteria  per  leucocyte  is  then  calculated  for 
each  specimen,  which  constitutes  the  phagocytic  index.  The  phagocytic 
index  of  the  patient  "s  serum  divided  by  the  phagocytic  index  of  the  normal 
or  control  serum  gives  the  opsonic  index.  The  test  can  only  be  carried  out 
properly  in  a  well-equipped  laboratory  by  one  who  has  mastered  opsonic 
technic.  The  strength  of  the  bacterial  emulsion,  the  length  of  incubation, 
the  age  of  the  ingredients  employed,  and  the  personal  equation  are  some  of 
the  factors  which  influence  the  results.  Opsonic  index  is  employed  in  the 
diagnosis  and  prognosis  of  certain  infectious  diseases  and  in  gauging  the 
dose  and  the  frequency  of  administration  of  bacterial  vaccines.  After  the 
injection  of  therapeutic  doses  of  bacterial  vaccines,  the  index  is  seen  pri- 
marily to  fall  and  soon  afterwards  to  rise  above  the  normal.  The  initial  fall 
constitutes  the  "negative  phase"  and  the  rise  the  "positive  phase."  The 
vaccine  should  not  be  repeated  until  the  negative  phase  has  passed  into  the 
positive,  and  this  can  only  be  gauged  by  repeated  observations  of  the  index. 
The  value  of  the  opsonic  index  for  therapeutic  or  diagnostic  purposes  has 
not  been  definitely  settled. 

Test  for  the  Detection  of  Glucose  in  the  Blood. — The  presence  of 
hyperglycemia  is  so  important  clinically  that  the  amount  of  sugar  in  the 
blood  must  be  determined  exactly.  The  Lewis-Benedict  method  gives  a  very 
accurate  estimation.  The  red  color  secured  by  heating  a  glucose  solution 
with  picric  acid  and  sodium  carbonate  is  used  as  a  basis  of  the  colorimetric 
determination. 

Technic. — Dilute  2  c.c.  of  blood  with  8  c.c.  of  water  and  add  15  c.c. 
of  a  concentrated  picric  acid  solution.  The  proteins  are  precipitated. 
Filter;  add  2  c.e.  of  concentrated  picric  acid  solution  and  1  c.c.  of  10  per 
cent,  sodium  carbonate  to  8  c.c.  of  the  filtrate.  Evaporate  to  a  small  volume 
or  to  dryness,  add  a  small  amount  of  water  and  bring  to  the  boiling  point. 
Transfer  to  a  10  c.c.  flask  and  make  up  the  volume  by  addition  of  water, 
filter  and  compare  in  a  Duboscq  colorimeter  with  a  standard  pieramie  arid 
solution  that  is  so  prepared  as  to  correspond  in  color  to  that  produced  by 
0.64  mg.  of  dextrose  under  conditions  described  in  test.  According  to  these 
authors  the  blood-sugar  content  of  healthy  persons  averages  about  0.1  per 
cent. 

Test  for  the  Determination  of  Acetone  in  the  Blood. — Dilute  10  c.c.  of 
blood  with  40  e.C.  of  a  .■")  per  cent,  solution  of  potassium  oxalate  and  distil 
15  c.c.  from  this  mixture.  Acidulate  with  ILKO,  and  re-distil  5-8  c.c.  The 
acetone  is  in  the  second  distillate.  Determine  its  presence  and  quantity  in' 
the  iodoform  method  of  estimation. 


264  MEDICAL  DIAGNOSIS. 

General  Results  of  Blood  Examinations. 

Volume.  —  The  blood,  which  forms  from  4  per  cent,  to  7  per  cent, 
of  the  total  body  weight,  is  a  highly  specialized  tissue,  consisting  of  eryth- 
rocytes,  leucocytes,  blood-plaques,  and  haemokonia,  suspended  in  a  liquid 
matrix,  the  plasma.  In  health  the  total  volume  of  blood  varies  within 
narrow  limits.  The  view  formerly  entertained  that  an  increase  in  the 
total  amount  is  constantly  present  in  some  individuals — plethora — is  not 
sustained  by  recent  researches.  Oligcemia,  or  a  decrease  in  the  total  quan- 
tity,— e.g.,  due  to  a  copious  hemorrhage, — persists  only  for  a  short  time 
after  the  bleeding,  as  the  volume  is  rapidly  brought  up  to  its  normal 
standard  by  the  absorption  of  fluid  from  6thcr  tissues,  which  dilutes  the 
remaining  blood,  producing  a  condition  termed  hydrcemia  or  serous  pleth- 
ora. Rapid  abstraction  of  watery  elements  from  the  blood  by  sweating, 
diarrhoea,  or  vomiting  causes  a  transitory  increase  in  its  density,  known 
as  anhydramia. 

Color. — The  color  of  the  arterial  blood  is  bright  red,  due  to  the  presence 
of  a  large  amount  of  oxyhaemoglobin,  while  that  of  venous  blood,  which 
contains  less  oxyhemoglobin  and  much  carbon  dioxide,  is  dark  red  or 
purple.  In  some  pathological  states,  as  in  diabetes  mellitus  and  in  leu- 
kaemia, the  blood  often  has  a  milky  tint;  a  peculiar  chocolate  color  is  some- 
times imparted  to  the  blood  by  poisoning  with  potassium  chlorate,  nitro- 
benzol,  and  hydrocyanic  acid.  Imperfect  aeration,  encountered  in  some 
diseases  of  the  respiratory  organs  and  heart  and  in  chronic  polycythsemia 
with  splenic  enlargement  (Osier's  disease),  causes  dark  red  blood  similar  to 
the  color  of  venous  blood.    In  carbon  monoxide  poisoning  it  is  bright  scarlet. 

Reaction. — The  reaction  of  normal  blood  is  alkaline.  The  degree  of 
alkalescence  varies  considerably  both  in  health  and  in  disease.  None  of 
the  methods  of  determining  the  intensity  of  this  reaction  has  been  gen- 
erally adopted  for  routine  clinical  purposes,  and,  as  the  results  of  various 
methods  are  not  uniform,  comparative  studies  by  different  observers  are 
in  the  main  inaccurate.  The  adoption  of  some  standard  technic  may 
establish  definite  results,  but  up  to  the  present  time  the  data  bearing 
upon  this  subject  are  insufficient  to  warrant  positive  opinions.  Statistics 
indicate  that  the  alkalinity  is  lowered  in  many  pathological  conditions, 
notably  in  diabetic  coma,  in  many  of  the  infectious  diseases,  especially 
in  Asiatic  cholera,  in  organic  hepatic  disease,  in  uraemia,  in  cachectic  states, 
in  a  considerable  group  of  skin  affections,  in  poisoning  by  mineral  acids,  and 
in  a  number  of  other  conditions.  In  chlorosis  and  rheumatic  fever  it  has 
been  found  increased. 

Specific  Gravity.  —  The  specific  gravity  of  normal  blood  is  about 
1.060.  It  fluctuates  slightly  in  health,  while  in  disease  there  are  wide 
oscillations.  The  specific  gravity  range  is  decidedly  influenced  by  the 
amount  of  haemoglobin,  and  so  close  is  the  relation  between  the  two  that 
an  approximate  haemoglobin  estimation  can  be  made  by  determining 
its  specific  gravity.  Exceptions  to  this  rule  are  found  in  the  case  of  leu- 
kaemia, in  which  the  range  of  specific  gravity  would  indicate  a  higher 
haemoglobin  value  than  actually  exists,  while  in  pernicious  anaemia  the 
reverse  is  true. 


EXAMINATION  OF  THE  BLOOD.  265 

Coagulation  of  the  Blood.  —  Within  a  short  time  after  blood  has 
been  withdrawn  from  the  circulation  of  a  healthy  individual,  it  under- 
goes coagulation,  a  process  which  determines  the  formation  of  fibrin  and 
the  separation  of  a  clear,  straw-colored  fluid,  the  blood-serum.  In  a  num- 
ber of  diseases  considerable  importance  is  attached  to  the  determination 
of  the  time  required  for  clotting.  Delayed  coagulation  is  encountered 
in  persons  suffering  from  obstructive  jaundice,  purpura,  scurvy,  and  haemo- 
philia. In  pernicious  anaemia,  in  some  cases  of  leukaemia,  and  at  times 
in  Hodgkin's  disease,  the  rate  of  coagulation  is  prolonged.  In  some  of 
the  infectious  fevers,  and  in  acute  inflammation  attended  with  abscess 
formation,  clotting  is  retarded,  while  in  chlorosis,  pneumonia,  and  scarlet 
fever  it  is  rapid. 

The  Plasma. — The  plasma,  a  complex  albuminous  body,  which  holds 
in  suspension  the  solid  elements  and  in  solution  many  organic  and  inor- 
ganic compounds,  is  the  vehicle  through  which  substances  are  transported 
to  the  tissues  and  waste  products  carried  to  the  excretory  organs.  The 
plasma  also  holds  certain  bodies  possessing  antitoxic,  bactericidal,  ag- 
glutinative, and  opsonic  properties.  Agglutinins  are  of  importance  in 
the  diagnosis  of  many  infectious  diseases,  as  in  enteric  fever,  paratyphoid 
infections,  Malta  fever,  cholera,  relapsing  fever,  and  dysentery.  Some 
observers  have  noted  this  reaction  in  tuberculosis,  pneumococcus  and 
streptococcus  infections,  plague,  and  leprosy. 

Erythrocytes.  —  The  red  blood-corpuscles  in  a  preparation  of  fresh 
blood,  taken  from  the  peripheral  circulation  of  a  healthy  person,  appear 
as  pale  yellowish-green,  non-nucleated,  flattened,  biconcave  cells  of  a 
circular  outline.  They  are  pliable,  somewhat  elastic,  non-amoeboid,  trans- 
parent, and  show  a  tendency  to  form  into  groups  or  rolls  when  withdrawn 
from  the  circulation,  and  consist  of  a  fine  stroma  which  holds  an  all  lu- 
minous iron  compound,  the  haemoglobin.  Structural  alterations  of  these 
cells  occur  when  blood  is  removed  from  the  circulation.  They  occasion- 
ally exhibit  amoeboid  activity  and  may  undergo  disintegration,  fragmen- 
tation, vacuolation,  and  crenation.  A  crenated  corpuscle  is  a  shrunken 
cell  from  which  knob-like  processes  project.  Structural  alterations  similar 
to  those  caused  by  withdrawing  the  blood  from  the  vessels  occur  within 
the  circulation  as  a  result  of  pathological  factors. 

Staining  Reaction  of  the  Erythrocyte. — The  normal  red  blood-cell, 
when  properly  fixed,  has  a  monochromatophilic  reaction,  showing 
a  selective  affinity  for  acid  dyes,  while  the  living  cell  does  not  absorb 
stains  (achromatophilic).  On  account  of  its  biconcavity,  the  central 
part  of  the  cell  stains  less  intensely  than  the  peripheral  zone.  The  long 
diameter  of  the  majority  of  the  healthy  cells  measures  about  7.5  microns, 
while  its  variations  are  between  6  and  9  macrons. 

Hsemogenesis  and  Haemolysis. — It  appears  to  be  definitely  established 
that  in  the  adult  the  red  bone-marrow  is  the  chief,  if  not  the  only  seat 
of  erythrocytic  formation.  The  colored  cells  develop  from  nucleated 
elements,  erythroblasts,  situated  along  the  walls  of  capillary  .-paces  of 
the  marrow.  Some  authorities  contend  that  erythroblasts  and  certain 
forms  of  immature  leucocytes  are  derived  from  a  common  ancestral  cell. 
The   spleen    and    lymphatic    glands   are   regarded    by  some  as   sources   of 


266  MEDICAL  DIAGNOSIS. 

erythrocytic  formation,  a  view  which  is  not  entertained  by  many  writers. 
The  fairly  uniform  number  maintained  in  the  circulating  blood  of  the 
healthy  individual  depends  upon  the  existence  of  a  parallelism  between 
the  rate  of  formation  and  the  rate  of  destruction.  Pathological  erythro- 
cytic destruction,  unless  excessive  or  prolonged,  excites  augmentation 
in  the  activity  of  erythroblastic  multiplication  and  is  followed  by  an 
increase  in  the  output  of  red  cells  from  the  marrow.  Most  authorities 
maintain  that  the  liver  and  in  a  less  degree  the  spleen  and  the  gastro- 
intestinal capillary  area  are  concerned  in  destroying  weakened,  degener- 
ated, or  necrotic  cells;  while  some  hold  that  the  bone-marrow  also  has  a 
haemolytic  function.  The  coloring  material  derived  from  the  disintegrated 
cells  is  in  part  transformed,  in  the  liver,  into  bile  pigment  and  eliminated 
through  the  biliary  channels,  in  part  discharged  by  the  kidneys,  and  prob- 
ably, to  a  considerable  extent,  stored  up  in  many  of  the  tissues  where  it 
is  available  for  future  needs  of  the  body. 

Number  of  Red  BIood=celIs.  —  The  norma/  number  of  erythrocytes, 
which  is  5,000,000  per  cubic  millimetre  for  an  adult  male  and  4,500,000 
for  an  adult  female,  is  subject  to  slight  variations  under  certain  phys- 
iological conditions  and  to  pronounced  alterations  in  many  morbid  states. 
A  decrease  in  the  number  is  termed  oligocythemia,  while  an  increase 
is  designated  polycythemia.  High  counts  are  at  times  an  indication  of  a 
decrease  in  the  volume  of  plasma  causing  a  relative  polycythemia.  After 
blood  transfusion,  and  after  active  blood  regeneration,  a  temporary  rise 
may  be  noted.  Polycythemia  is  encountered  in  the  new-born,  where  it 
exists  for  some  days  after  birth — probably  not  exceeding  ten — in  indi- 
viduals residing  in  high  altitudes,  and  in  robust  and  well-developed  per- 
sons. Massage,  electricity,  and  cold  bathing  may  also  induce  an  increase 
in  the  erythrocytes  in  the  peripheral  blood.  A  slight  reduction  in  the 
erythrocytes  is  brought  about  by  pregnancy,  menstruation,  and  lactation; 
it  is  also  met  with  in  poorly  nourished  individuals,  in  those  who  are 
fatigued,  and  during  the  period  of  digestion.  Oligocythemia,  due  to 
physiological  causes,  may  sometimes  be  accounted  for  by  temporary  dilu- 
tion of  the  blood,  while  in  other  instances  an  absolute  decrease  in  the 
number  of  cells  offers  the  best  explanation. 

In  pathological  states  a  relative  transitory  increase  arises  when  the 
output  of  fluid  from  the-  body  is  decidedly  in  excess  of  the  intake,  and 
is  therefore  conspicuous  in  diseases  associated  with  marked  polyuria,  as 
diabetes,  with  copious  sweating,  as  from  night  sweats  of  pulmonary  tuber- 
culosis, with  frequent  vomiting,  with  profuse  diarrhoea,  as  in  Asiatic  cholera, 
and  after  the  withdrawal  of  a  large  quantity  of  fluid  from  a  serous  cavity, 
which  rapidly  reaccumulates,  thereby  draining  the  blood  of  much  fluid. 
The  pathological  factors  responsible  for  oligocythemia  are  numerous, 
and  in  the  vast  majority  of  diseases  associated  with  lowered  counts  the 
reduction  depends  upon  increased  blood  destruction,  in  some  it  may  be 
due  to  defective  blood  formation,  or  to  a  combination  of  both  of  these 
factors,  while  in  others  a  slight  transitory  decrease  is  brought  about  by 
blood  dilution — whenever  the  amount  of  fluid  taken  into  the  body  is 
above  the  output  of  liquid.  Lowered  erythrocytic  standards  are  noted 
in  the  primary  anemias,  notably  pernicious  anemia,  in  which  the  figure 


EXAMINATION  OF  THE  BLOOD.  267 

often  falls  as  low  as  one  million,  and  in  occasional  instances  below  half 
a  million.  Secondary  anaemias  arise  from  a  great  variety  of  causes,  as 
from  infections  due  to  bacteria  and  animal  parasites,  metallic  poisoning, 
organic  visceral  disease,  hemorrhage,  and  many  others. 

The  Haemoglobin.  —  Haemoglobin,  a  complex  albuminous  compound 
containing  iron  which  is  a  component  of  the  red  cells,  normally  exists 
in  two  chemical  states,  in  combination  with  oxygen  (oxyhaemoglobin) 
and  as  reduced  or  plain  haemoglobin.  Normal  blood  contains  about  14 
per  cent,  of  haemoglobin.  A  reduction  of  haemoglobin,  termed  oligochromce- 
mia,  is  generally  associated  with  a  fall  in  the  number  of  erythrocytes. 
This  deficiency  of  corpuscles,  as  a  rule,  is  not  so  marked  as  the  haemo- 
globin loss,  although  sometimes  the  number  of  colored  elements  remains 
normal;  rarely  there  is  a  proportionate  reduction  of  the  coloring  matter 
and  of  the  number  of  cells,  or  the  latter  may  even  show  a  greater  percent- 
age reduction  than  the  haemoglobin.  An  insufficient  amount  of  haemo- 
globin in  the  corpuscles  is  brought  about  by  an  effort  on  the  part  of  the 
bone-marrow  to  rapidly  regenerate  cells  at  the  expense  of  perfect  forma- 
tion (i.e.,  after  or  during  rapid  haemolysis).  A  high  color  index  occurs  in 
pernicious  anaemia.  Investigations,  both  experimental  and  clinical,  have 
demonstrated  that  the  haemoglobin  rises  in  certain  anaemic  states  b}'  the 
administration  of  iron  compounds. 

Hcemoglobincemia,  the  term  which  implies  the  presence  of  haemo- 
globin in  solution  in  the  plasma,  is  due  to  a  number  of  causes,  and  is  at 
times  followed  by  the  excretion  of  haemoglobin  by  the  kidneys  (haemo- 
globinuria).  The  disease  known  as  paroxysmal  haemoglobinuria  is  a 
striking  example  of  the  latter  condition.  Among  the  conditions  capable 
of  producing  haemoglobinaemia  are  poisoning  by  sulphuric  acid,  nitro- 
benzol,  phenacetin,  acetanilid,  phenol,  hydrochloric  acid,  potassium  chlorate, 
mushrooms,  and  snake  venoms.  Haemoglobinaemia  is  excited  by  some  of 
the  infectious  diseases,  as  malarial  fever,  enteric  fever,  yellow  fever,  typhus 
fever,  variola,  septicaemia,  diphtheria,  and  syphilis;  also  by  malignant 
jaundice,  scurvy,  sunstroke,  burns,  and  from  exposure  to  intense  cold. 

Methcemoglobin,  another  combination  of  oxygen  and  haemoglobin, 
is  a  component  of  some  pathological  bloods  and  is  present  in  poisoning 
with  such  substances  as  potassium  chlorate,  aniline,  amyl  nitrite,  potas- 
sium permanganate,  antifebrin,  nitro-benzol,  hydrochinone,  potassium  feffo- 
cyanide,  and  snake  venom.  Carbon  monoxide  haemoglobine,  which  occurs 
in  coal-gas  poisoning,  gives  the  blood  a  bright  scarlet  appearance. 

Abnormal  Erythrocytes.  —  Cells  exhibiting  abnormal  variations  in 
size  are  common  in  anaemic  states,  particularly  small  erythrocytes  known 
as  micTOcytes,  which  have  a  diameter  of  less  than  6  microns,  and  when 
these  forms  predominate  in  the  blood  the  condition  is  termed  microcytosis 
or  microcythcemia.  This  change  is  conspicuous  in  chlorosis  ami  in  some 
secondary  anaemias  of  the  chlorotic  type.  Minute  erythrocytes,  spherical 
in  form,  with  a  deeply  colored  protoplasm,  are  often  described  as  Eich- 
horst'a  corpuscles.  Cells  measuring  more  than  (.)  microns  are  designated 
macrocytes,  and  when  these  abnormally  large  forms  outnumber  other 
colored  elements  macrocytosis  or  macrocythcemia  exists.  Typical  <■. 
of  pernicious  anaemia  show  an  average  increase  in  the  size  of  the  red  cells. 


268  MEDICAL  DIAGNOSIS. 

Rapid  or  defective  blood  formation  has  been  advanced  as  the  factor 
responsible  for  microcytosis,  although  structural  alteration  in  the  cells 
after  they  have  entered  the  circulation,  such  as  fragmentation  and  loss 
of  haemoglobin,  may  account  for  some  of  these  dwarfed  elements.  Macro- 
cytosis  appears  to  depend  upon  the  development  of  large  cells  in  the  mar- 
row, or  perhaps  it  is  due  to  swelling  of  the  protoplasm  of  the  erythrocytes 
while  in  the  general  circulation. 

Poikilocytes  are  cells  having  an  irregular  or  distorted  outline  and 
often  appear  as  pear-shaped,  elongated,  oval,  and  "hour-glass"  forms. 
These  pathological  cells  show  wide  variations  in  size  and  in  staining  pecu- 
liarities. The  degree  of  cell  deformity  and  the  extent  of  the  variation  in 
size  are  generally  proportionate  to  the  severity  of  the  anaemia.  Per- 
nicious anaemia  and  grave  secondary  anaemias  reveal  poikilocytosis  in 
its  most  typical  form.  Cells  so  deficient  in  haemoglobin  that  a  mere  color- 
less shell  remains  are  termed  phantom  or  shadow  corpuscles  or  achroma- 
cytes.  Erythrocytes  which  react  indifferently  and  irregularly  to  acid  and 
basic  dyes,  staining  diffusely  with  both, — termed  polychromatophilic  cells, — 
are  observed  in  profound  anaemias,  particularly  in  progressive  pernicious 
anaemia.  They  appear  in  specimens  stained  with  eosin-methylene-blue 
mixtures,  as  purple,  brownish,  or  bluish  cells,  their  color,  as  a  rule,  being 
unevenly  distributed,  and  in  some  instances  only  a  part  of  the  protoplasm 
exhibits  this  altered  tinctorial  reaction.  The  cytoplasm  of  nucleated 
red  cells,  especially  of  the  megaloblast,  often  shows  this  change.  Some 
authorities  maintain  that  this  abnormal  staining  quality  is  an  indication 
of  immature  cell  development,  while  others  regard  it  as  a  sign  of  stroma 
degeneration.  Oval  or  "ring-like"  bodies  reacting  to  basic  dyes  are  occa- 
sionally observed  in  the  red  cells  which  some  students  assert  are  the  remains 
of  a  nuclear  structure.  Red  cells  which  contain  granular  areas  having 
a  basic  stain  affinity  scattered  through  the  cytoplasm,  appearing  in  some 
corpuscles  as  a  fine  stippling  and  in  others  as  coarse  irregular  granules,  are 
described  as  cells  showing  granular  basophilia.  This  condition  is  observed 
in  severe  anaemias,  especially  of  the  pernicious  type,  in  leukaemia,  and 
constantly  in  chronic  lead  poisoning.  Some  investigators  regard  it  as  an 
indication  of  degeneration  of  the  cells,  while  others  are  inclined  to  view 
this  feature  as  an  evidence  of  nuclear  fragmentation. 

Nucleated  Red  Blood-cells.  —  Nucleated  red  blood-corpuscles 
are  normally  found  in  the  blood  during  the  early  months  of  fetal  life  and 
in  the  blood-marrow  of  all  individuals.  Two  principal  types  are  found, 
normoblasts   and   megaloblasts. 

Normoblasts.  —  This  cellular  element,  a  normal  constituent  of  the 
bone-marrow  of  the  healthy  adult,  is  about  the  size  of  the  normal  erythro- 
cyte, and  consists  of  a  single  oval  or  round  nucleus  (rarely  two  or  three), 
which  reacts  intensely  to  basic  stains,  while  the  cytoplasm  has  an  acido- 
philic affinity  like  a  normal  erythrocyte.  At  times  this  cell  contains  an 
irregularly  shaped  nucleus  or  several  may  be  noted  in  a  single  cell.  The 
nucleus  is  often  eccentrically  placed,  and  sometimes  extrudes  from  the 
cell  or  may  be  found  free  in  the  plasma.  The  occurrence  of  normoblasts 
in  the  circulation  of  the  adult  is  generally  regarded  as  a  sign  of  rapid  blood 
regeneration,  well  illustrated  after  a  profuse  traumatic  hemorrhage,  where 


EXAMINATION  OF  THE  BLOOD.  269 

large  numbers  of  these  cells  often  are  present  in  the  blood,  a  condition 
which  Von  Noorden  has  termed  "blood  crisis."  Cells  having  the  diameter 
ranging  from  4  to  6  microns,  with  a  round  or  oval  nucleus  reacting  sharply 
to  basic  dyes,  and  a  shrunken  irregular  protoplasm,  called  microblasts, 
probably  represent  normoblasts  having  a  degenerated  cytoplasm.  Megal- 
oblasts  vary  in  size  between  1 1  and  20  microns  in  diameter,  and  consist 
of  a  large  nucleus  of  loose  texture  staining  feebly,  surrounded  by  a  com- 
paratively small  amount  of  cytoplasm.  A  clear  hyaline  space  or  ring 
sometimes  separates  the  nucleus  from  the  protoplasm,  which  not  infre- 
quently has  a  polychromatophilic  reaction.  Fetal  bone-marrow  normally 
contains  megaloblasts.  Most  writers  regard  the  presence  of  megaloblasts  in 
the  circulating  blood  of  the  adult  an  indication  of  a  reversion  of  the  marrow 
activity  to  an  earlier  type  similar  to  that  found  in  the  foetus.  These  cells 
are  found  in  grave  forms  of  anaemia,  as  typified  in  pernicious  anaemia. 

Blood=platelets. — Blood-platelets,  or  blood-plaques,  are  small,  spher- 
ical, oval,  or  irregular  bodies,  having  a  pale  yellowish  color,  and  measure 
from  1  to  4  microns  in  diameter.  They  are  not  endowed  with  amoeboid 
activity,  and  stain  with  both  acid  and  basic  dyes.  Blood-plaques  disap- 
pear rapidly  after  the  blood  is  exposed  to  the  air.  Some  writers  con- 
sider  these   elements   as   being  derived  from   fragmented  red  blood-cells. 

Technic  of  Counting  Blood-platelets  (Method  of  Wright  and  Kinnicutt). — 
Two  parts  of  cresyl  blue  (1  :  300)  are  mixed  with  three  parts  of  potassium 
cyanide  (1  :  14000)  and  rapidly  filtered,  then  immediately  used  to  dilute  the 
blood  1  :  100.  The  blood  must  be  from  a  free-flowing  drop  and  the  whole 
procedure  must  be  carried  out  as  quickly  as  possible.  Variations  under 
physiological  and  pathological  influences  are  common.  In  many  severe 
secondary  anaemias,  in  leukaemia,  in  chlorosis,  and  in  rheumatoid  arthritis 
an  increase  is  encountered,  while  in  pernicious  anaemia  their  number  is 
generally  reduced.  In  some  of  the  specific  infectious  diseases,  particu- 
larly in  pneumonia  and  in  bubonic  plague,  an  increase  is  found,  while 
in  others,  notably  in  erysipelas,  in  malaria,  and  in  typhus  fever,  there 
is  a  decrease.  The  average  per  cubic  millimetre  at  sea  level  is  302,000, 
and  340,000  at  an  altitude  of  6000  feet — a  percentage  increase  of  12.2. 
(Webb  and  Gilbert.)  They  are  consistently  increased  in  tuberculosis  of 
man  and  guinea-pigs.  A  marked  reduction  is  frequently  seen  in  purpura 
and  haemophilia. 

Haemokonia. — In  fresh  unstained  blood  there  are  found,  in  the  plasma, 
small,  transparent,  highly  refractile  bodies,  not  exceeding  one  micron  in 
diameter,  of  spherical,  oval,  or  dumb-bell  shape,  possessing  active  molec- 
ular motion,  which  are  termed  hsemokonia,  or  blood  dust.  These  bodies 
are  insoluble  in  ether  or  alcohol  and  do  not  stain  with  osmic  acid.  Their 
significance  is  as  yet  unknown;  it  has  been  suggested  that  they  represent  frag- 
ments of  cells  or  free  cell  granules,  as  eosinophilic  or  neutrophilic  granules. 

Leucocytes. — The  leucocytes,  or  white  blond-corpuscles,  in  a  wet  prepa- 
ration of  fresh  Mood  taken  from  a  normal  individual,  appear  as  pale,  color- 
less, nucleated  cells,  the  greater  number  of  which  are  granular  and  endowed 

with  amoeboid  activity.  Ehrlich's  classification  is  generally  adopted  for 
clinical  work.  The  following  table  includes  the  main  varieties  of  leucocytes 
with  their  relative  percentages  present  in  the  blood  of  the   normal   adult: 


270  MEDICAL  DIAGNOSIS. 

Polynuclear    neutrophiles 60-70  per  cent. 

Eosinophiles     5—  4  per  cent. 

Basophiles  or  mast-cells 025-  .5  per  cent. 

Small  lymphocytes 20-30  per  cent. 

Large  lymphocytes,  hyaline  cells,  and  transitional  forms.         4-  8  per  cent. 

In  infancy  the  percentage  of  lymphocytes  is  greater  than  in  adult 
life,  while  eosinophiles  may  reach  as  high  as  14  per  cent,  in  childhood. 

Polynuclear  Neutrophiles. — These  cells,  the  diameter  of  which  ranges 
between  lh  and  11  microns,  have  an  irregular  nucleus,  appearing  in  various 
shapes,  as  in  the  form  of  the  letters  U,  Z,  S,  and  a  finely  granular  pro- 
toplasm. The  irregularly  shaped  nucleus,  which  is  composed  of  enlarge- 
ments or  lobes  connected  by  bands,  reacts  to  basic  dyes  with  marked 
affinity.  The  granules  are  fine,  of  an  irregular  outline,  and  absorb  acid 
dyes  (finely  granular  oxyphile  cells).  According  to  Ehrlich,  the  granules 
have  a  neutral  staining  property.  The  polynuclear  neutrophiles  possess 
amoeboid  and  phagocytic  properties. 

Eosinophiles  or  polynuclear  eosinophiles  (coarsely  granular  oxyphiles) 
are  about  the  size  of  or  slightly  larger  than  the  normal  erythrocyte, 
their  diameter  ranging  from  7  to  10  microns.  They  possess  a  nucleus 
similar  in  structure  and  tinctorial  qualities  to  that  of  the  polynuclear 
neutrophile;  their  protoplasm  contains  coarse,  highly  refractile,  oval  or 
spherical  granules,  staining  deeply  with  acid  dyes.  They  are  endowed 
with  active  amoeboid  qualities. 

Basophiles  or  Mast=cells. — Under  this  term  are  classified  leucocytes 
which  have  a  lobed  or  twisted  nucleus  like  that  of  the  neutrophiles  and  a 
cytoplasm  beset  with  very  irregularly  shaped  basophilic  granules  of  varying 
size.  The  granules  are  not  colored  with  Ehrlich's  triple  stain,  but  may  be 
plainly  seen  when  treated  with  Leishman's  or  Ehrlich's  dahlia  mixture. 

Small  Lymphocytes.  —  These  are  essentially  non-granular  cells,  the 
majority  being  about  the  size  of  the  normal  erythrocyte.  They  consist 
of  a  large  circular  or  oval  nucleus,  which  has  a  decided  basic  property 
and  a  relatively  small  amount  of  protoplasm,  reacting  feebly  to  basic 
and  occasionally  to  acid  stains.  With  Ehrlich's  triple  stain,  the  cytoplasm 
is  colored  a  pale  pink  or  gray,  while  with  Leishman's  eosin-methylene- 
.  blue  mixture,  a  light  blue,  showing  less  basic  affinity  than  the  nucleus. 
Lymphocytes  treated  with  Leishman's  stain  occasionally  show  a  few 
fine  pink  granules  in  their  cytoplasm.  These  cells  are  neither  amoeboid 
nor  phagocytic. 

Large  Lymphocytes.  —  Several  varieties  of  leucocytes  are  embraced 
under  this  heading — lymphocytes  proper  of  large  site,  generally  regarded 
as  the  product  of  lymphatic  tissue,  and  large  mononuclear  or  hyaline  cells, 
probably  of  bone-marrow  origin.  A  distinction  cannot  always  be  made 
between  large  lymphocytes  and  hyaline  cells,  since  they  resemble  each 
other  as  to  structure  and  tinctorial  reactions.  The  nucleus  of  the  latter 
cell  is  round  or  oval.  The  protoplasm  of  the  lymphocyte  has  a  slightly 
stronger  basic  affinity  than  that  of  the  large  mononuclear.  From  a  clinical 
standpoint  this  differentiation  does  not  appear  important.  The  large 
lymphocytes  have  a  relatively  smaller  nucleus  than  the  small  forms,  and 
stain  less  intensely.  Transitional  forms  closely  resemble  large  lympho- 
cytes   and    hyaline   cells   in    size   and   staining   qualities,   but    differ  from 


DESCRIPTION  OF  PLATE  IV. 

1.  Neutrophile  myelocyte. 

2.  Neutrophile  myelocyte  showing  indentation  of  its  nucleus. 
3,  4.  Neutrophile  myelocytes. 

5,  6,  7,  8,  9,  10.  Polynnclear  neutrophiles. 
11, 12.  Eosinophile  myelocytes. 
13, 14, 15, 16.  Polynnclear  eosinophiles. 
17.  Basophile  myelocyte. 
18,  19.  Polynnclear  basophiles. 

20.  Blood  platelets. 

21.  Large  mononuclear  form. 
22,  23.  Transitional  forms. 

24,  25.  Large  lymphocytes. 

26.  Lymphocyte  showing  acidophilic  granules  in  its  protoplasm. 
27,  28,  29.  Small  lymphocytes. 
30,  31,  32.  Normal  erythrocytes. 
33,  34.  Microcytes. 
35.  Macroeyte. 
36,  37,  38,  39,  40,  41.  Poikilocytes. 

42,  43,  44,  45.  Erythrocytes  containing  basophilic  granules. 

46.  Erythrocyte  exhibiting  poly  chromatophiha  and  granular  basophilia. 

47.  Megaloblast. 
48,  49,  50.  Normoblasts. 

51,  52,  53.  Erythrocytes  with  polychromatophilic  protoplasm. 

(Leishman's  Stain.) 


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EXAMINATION  OF  THE  BLOOD.  271 

these  leucocytes  in  having  an  indented  or  distorted  nucleus,  resembling 
the  form  of  the  nucleus  of  some  of  the  polynuclear  neutrophiles. 

Hyaline  cells  are  said  to  possess  active  phagocytic  and  amoeboid 
properties. 

Myelocytes. — These  cells,  which  are  normal  constituents  of  the  bone- 
marrow  and  only  present  in  the  blood  in  pathological  states,  are  in  the 
main  large  cells  supplied  with  a  large  circular,  oval,  or  slightly  indented 
nucleus,  staining  feebly  with  basic  principles,  and  surrounded  by  a  granular 
protoplasm. 

These  cells  are  classified  into  three  groups,  depending  on  the 
microchemical  reaction  of  the  cell-granules,  namely  into  neutrophilic, 
eosinophilic,  and  basophilic  varieties.  The  neutrophilic  myelocyte  is  the 
commonest  form.  Neutrophilic  granules  of  myelocytes  do  not  stain  as 
distinctly  as  those  found  in  the  polynuclear  cells.  Types  intermediate 
between  typical  polynuclear  neutrophiles  and  typical  neutrophilic  myelo- 
cytes are  observed  in  some  pathological  conditions,  especially  myelogenous 
leukaemia  and  not  infrequently  in  leucocytosis.  Myelocytes  often  show 
indistinct  granulations  embedded  in  a  feebly  basic  protoplasm;  these 
forms  are  considered  by  some  to  be  closely  related  to  cells  farther  back 
in  their  ancestral  development. 

Atypical  lymphocytes  are  not  infrequently  encountered  in  severe 
anaemias,  particularly  in  lymphatic  leukaemia.  Some  of  these  cells  are 
almost  devoid  of  protoplasm,  while  others  contain  a  distorted  nucleus. 
The  term  neutrophilic  pseudolymphocyte  has  been  suggested  for  those 
cells  which  have  a  round  nucleus,  rich  in  chromatin,  surrounded  by  a 
narrow  rim  of  protoplasm,  filled  with  neutrophilic  granules.  These 
leucocytes  may  represent  small  myelocytes,  as  their  color  character- 
istics, excluding  the  strong  basic  nucleus,  suggest  neutrophile  myelo- 
cytes. Turk  employs  the  name  "stimulation  form"  for  moderately 
large  leucocytes  having  a  single  round  weakly  basophilic  nucleus,  and 
a  non-granular  cytoplasm,  which  stains  a  brown  color  with  the  triple 
mixture. 

Development  of  Leucocytes. — Most  authorities  regard  the  bone-mar- 
row and  the  lymphatic  tissues  as  the  seats  of  leucocyte  formation,  the 
former  being  concerned  in  the  development  of  polynuclear  neutrophiles, 
eosinophils,  basophilic  and  hyaline  cells,  while  the  latter  appear  respon- 
sible for  the  production  of  lymphocytes.  In  the  bone-marrow  are  found 
groups  of  cells,  " leucoblastic  areas,"  consisting  of  myelocytes  surrounded 
by  polynuclear  elements,  while  erythroblastic  zones  are  present  princi- 
pally along  the  margins  of  vascular  spaces.  It  is  conceded  by  most  author- 
ities that  the  polynuclear  neutrophile  is  developed  from  the  neutrophile 
myelocyte,  the  polynuclear  eosinophil  from  the  eosinophile  myelocyte, 
and  a  basophilic  cell  from  its  parent  marrow  cell.  In  the  transformation 
of  the  myelocyte  into  the  polynuclear  leucocyte,  the  nucleus  undergoes 
condensation  and  lobulation,  the  size  of  the  cell  decreases,  and  the  stain- 
ing reaction  of  the  nucleus  and  of  the  granules  intensifies.  The  Large 
mononuclear  or  hyaline  and  transitional  leucocytes  are  probably  formed  in 
the  marrow.  The  Lymphocytes  are  derived  from  lymphatic  tissue,  the 
small  form  being  the  progeny  of  the  large  cell. 


272  MEDICAL  DIAGNOSIS. 

Number  of  Leucocytes.  —  Many  circumstances  affect  the  number 
of  leucocytes  in  the  circulation.  The  colorless  corpuscles  range  between 
6000  and  8000  per  cubic  millimetre  in  a  healthy  person;  this  standard 
is,  however,  subject  to  slight  variations,  beyond  these  limits,  in  certain 
physiological,  and  often  to  pronounced  alterations  in  pathological  states. 
The  number  is  influenced  by  the  condition  of  body  nutrition,  e.g.,  in  pro- 
longed starvation  low  counts  are  conspicuous,  by  unequal  distribution 
of  the  cells,  by  blood  dilution  and  by  blood  inspissation.  The  most  ac- 
ceptable theory,  advanced  to  explain  the  occurrence  of  an  increase  in  the 
number  of  colorless  elements  (leucocytosis)  in  disease,  points  out  that 
irritants  acting  in  the  tissues  produce  chemical  substances  which  attract 
certain  leucocytes  towards  the  seat  of  mischief,  and  cause  the  leucocyte 
forming  organs  to  pour  out  an  increased  number  of  cells.  This  attraction 
force  has  been  termed  "positive  chemotaxis,"  in  contradistinction  to  a 
repelling  action  set  up  by  some  irritants  called  "negative  chemotaiis." 
The  degree  of  leucocytosis  depends  mainly  upon  the  intensity  of  the  chemo- 
tactic  force  and  the  responding  powers  of  the  individual. 

Leucocytosis. — The  term  leucocytosis  or  hyperleucocytosis  designates 
an  increase  in  the  number  of  leucocytes  in  the  peripheral  blood  over  the 
normal  standard.  This  increase,  as  a  rule,  involves  a  marked  percentage 
gain  in  the  polynuclear  neutrophile  elements  with  a  fall  in  the  percentage 
of  other  forms,  but  sometimes  comprises  a  proportionate  rise  in  all  the 
varieties,  or  a  percentage  gain  in  the  lymphocytes,  eosinophiles,  or  baso- 
philes.  Leucocytosis  is  classified  into  special  forms,  depending  on  physi- 
ological or  pathological  disturbances;  these  types  being  further  subdivided 
into  special  varieties,  dependent  upon  certain  etiological  factors, — e.g., 
digestive,  inflammatory,  toxic,  malignant,  and  post-hemorrhagic  leucocy- 
tosis. A  rise  in  the  number  of  polynuclear  neutrophile  cells  is  called  polynu- 
clear neutrophile  leucocytosis;  an  augmentation  in  lymphocytes  is  termed 
lymphocytosis;  an  increase  of  eosinophiles  is  known  as  eosinophilia;  the 
latter  forms  also  being  sub-grouped  into  (a)  an  absolute  and  (b)  a  relative 
increase;  e.g.,  absolute  lymphocytosis  is  shown  by  a  gain  in  the  total  count 
with  a  rise  in  the  percentage  of  lymphocytes,  while  relative  lymphocytosis 
implies  a  percentage  gain  without  an  increase  in  the  total  number  of  these 
cells.  The  terms  absolute  and  relative  as  applied  to  leucocytosis  are  often 
misleading  to  the  student. 

Physiological  Leucocytosis — The  leucocytosis  which  depends  upon  phys- 
iological factors  is,  in  the  main,  slight,  of  short  duration,  and  commonly 
involves  a  proportionate  increase  in  all  of  the  forms  of  leucocytes,  less  often 
an  absolute  and  a  relative  gain  in  the  polynuclear  neutrophile  elements. 

Leucocytosis  of  Digestion.  —  In  nearly  all  healthy  individuals, 
during  the  period  of  digestion,  from  one  to  four  hours  after  taking  food, 
a  slight  rise  in  the  number  of  leucocytes  is  present,  which  generally  consists 
of  an  absolute  increase.  Some  claim  that  the  gain  principally  involves 
the  neutrophiles,  while  others  assert  the  lymphocytes  are  responsible. 
In  the  new-born,  leucocytosis  of  digestion  is  pronounced.  In  starvation 
and  frequently  in  the  morbid  states  associated  with  faulty  nutrition,  the 
number  of  white  corpuscles  decreases.  The  rapidity  with  which  digestion 
leucocytosis  manifests  itself  after  taking  food  is  regarded  by  some  writers 


EXAMINATION  OF  THE  BLOOD.  273 

as  bearing  a  direct  relation  to  the  activity  of  the  digestive  function.  In 
persons  suffering  from  gastric  ulcer,  leucocytosis  sometimes  comes  on  very 
soon  after  taking  food,  pointing  to  rapid  digestion;  while  in  gastric  cancer, 
it  may  be  delayed  or  absent.  This  rule  is  not  constant  and  little  importance 
should  be  attached  to  digestion  leucocytosis  in  diagnosis. 

Leucocytosis  Occurring  during  Pregnancy  and  after  Parturi- 
tion.— A  moderate  rise  in  the  number  of  leucocytes  occurs  during  the  later 
months  of  pregnancy,  and  persists  for  about  two  weeks  after  parturition. 

Leucocytosis  of  the  New-born*. — The  high  counts  observed  for 
about  ten  days  after  birth  are  attributed  to  blood  inspissation  and  to  the 
establishment  of  digestion  leucocytosis.  Higher  counts  are  present  in 
early  childhood  than  in  the  advanced  periods  of  life.  Leucocytic  oscilla- 
tions of  a  very  moderate  character  occur  after  exercise,  massage,  after 
cold  or  hot  bathing,  and  after  the  use  of  electricity. 

Pathological  Leucocytosis.  —  Inflammatory  and  Infectious  Leuco- 
cytosis.— The  presence  or  the  absence  of  a  leucocytosis  in  many  of  the 
infectious  and  inflammatory  diseases  is  a  sign  of.  considerable  importance 
in  diagnosis.  Its  clinical  value  is  comparable  in  a  measure  with  other 
signs,  such  as  temperature  range  and  pulse,  certain  physical  signs,  etc. 
This  pathological  increase,  which  is  essentially  a  polynuclear  neutrophile 
leucocytosis,  is  as  a  general  rule  encountered  in  acute  local  inflamma- 
tions, as  in  furuncles,  cellulitis,  abscesses,  in  general  sepsis,  and  in  nearly 
all  of  the  specific  infectious  diseases,  except  in  uncomplicated  cases  of 
enteric  fever,  paratyphoid  infections,  tuberculosis,  malaria,  measles, 
German  measles,  influenza,  leprosy,  and  Malta  fever.  High  leucocytic 
ranges  are  often  attributable  to  suppurative  inflammation.  Duration 
and  height  of  fever  have  no  direct  relation  to  the  leucocyte  curve.  Counts 
between  15,000  and  20,000  are  common,  while  ranges  above  30,000  are 
uncommon  and  above  50,000  very  rare. 

Preagonistic  or  Terminal  Leucocytosis.  —  The  exact  nature  of 
the  leucocytosis  which  so  often  precedes  death  is  still  a  mooted  question; 
many  investigators  attribute  this  rise  to  terminal  infections. 

Malignant  Leucocytosis. — Different  opinions  have  been  advanced 
to  explain  the  gain  of  colorless  elements  so  frequently  noted  in  individuals 
suffering  from  carcinoma  and  sarcoma.  Some  writers  contend  that  asso- 
ciated inflammatory  disturbance  about  the  growth  or  septic  absorption 
from  the  tumor  induces  the  leucocytic  gain,  while  others  hold  that  the 
direct  effect  of  the  tumor  is  the  responsible  factor.  In  rapidly  spreading 
malignant  growths,  especially  when  metastasis  has  occurred,  counts  are 
generally  high  and  much  above  those  noted  in  slowly  growing  tumors; 
in  sarcomata  the  gain  is  usually  more  pronounced  than  in  carcinomata. 
The  cellular  rise  in  the  majority  involves  mainly  the  neutrophiles,  although 
lymphocytosis,  especially  in  sarcomata,  has  been  recorded.  In  cases  of 
carcinoma  of  the  stomach,  leucocytosis  is  often  absent. 

POST-HEMORRHAGIC  LEUCOCYTOSIS. — The  gain  in  the  white  corpus- 
cles which  follows  and  persists  for  some  days  after  a  profuse  hemorrhage 
is  generally  accounted  for  by  an  increased  production  and  output  of  poly- 
nuclear neutrophiles.  Some  observers  hold  that  the  lymph  (rich  in  cells) 
which  passes  into  the  blood  after  blood  loss  is  the  responsible  factor. 
18 


274  MEDICAL  DIAGNOSIS. 

A  leucopenia,  lasting  for  a  few  hours,  precedes  the  leukocytosis  due  ta 
hemorrhage.     Leucocytosis  is  present  in  many  cases  of  secondary  anaemia. 

Leucocytosis  due  to  Toxic  and  Therapeutic  Agents. —  Among 
the  substances  capable  of  producing  a  rise  in  the  leucocytic  standard  may 
be  mentioned  quinine,  ether,  chloroform,  potassium  chlorate,  illuminat- 
ing gas.  salicylates,  uric  acid,  and  various  organic  extracts. 

Lymphocytosis.  —  This  condition,  an  increase  of  lymphocytes,  is 
normal  in  infants  and  in  young  children.  A  relative  lymphocytosis 
due  to  diminution  of  the  polynuclear  elements  has  been  recorded  in  the 
following  conditions:  chlorosis,  pernicious  anaemia,  severe  secondary 
anaemia,  and  in  some  of  the  infectious  diseases,  as  tuberculosis,  enteric 
fever,  malaria,  and  influenza.  A  lymphocytosis  is  sometimes  observed 
in  Hodgkin's  disease,  and  often  in  children  suffering  from  syphilis,  anaemia, 
pseudoleukaemia  infantum,  rickets,  whooping-cough,  and  gastro-intestinal 
diseases.  Diseases  of  the  lymphatic  glands  and  spleen  are  sometimes 
attended  by  an  increase  in  these  cells.  Lymphocytosis  in  most  instances 
is  a  relative  condition.  Absolute  lymphocytosis  of  high  grade  is  a  constant 
feature  of  lymphatic  leukaemia.  In  myelogenous  leukaemia  the  percentage 
of  lymphocytes  is  reduced,  although  the  total  number  is  increased. 

Eosinophilia. — An  increase  in  the  number  of  eosinophiles  has  been 
observed  in  the  blood  of  normal  infants,  in  anaemia  pseudoleukaemia 
infantum,  in  splenomedullary  leukaemia,  in  bronchial  asthma,  after  hemor- 
rhage, in  diseases  of  the  skin,  as  urticaria,  lupus,  eczema,  leprosy,  and 
pemphigus,  after  coitus,  during  convalescence  from  many  of  the  acute 
infectious  diseases,  in  bone  diseases  and  in  morbid  states  caused  by 
intestinal  worms,  particularly  in  trichiniasis.  Definite  conclusions  regard- 
ing the  clinical  significance  of  fluctuations  in  these  cells  in  morbid  states 
cannot  be  drawn  from  our  present  knowledge,  although  some  diagnostic 
importance  should  be  attached  to  the  almost  constant  eosinophilia  in 
trichiniasis,  in  ankylostomiasis,   and  in  bilharzial  infection. 

Basophilia. — This  term  is  used  to  express  an  increase  in  the  number 
of  basophiles  in  the  circulating  blood,  which  is  frequently  noted  in  spleno- 
medullary leukaemia.  Some  writers  have  reported  basophilia  in  splenic 
anaemia,  in  certain  skin  diseases,  in  acute  bone  inflammation,  and  in 
gonorrhoea.     The  clinical  significance  of  basophilia  remains  unsettled. 

Leucopenia. — A  decrease  in  the  number  of  leucocytes  is  termed  leuco- 
penia, or  hypoleucocytosis,  and  may  be  brought  about  by  physiological 
and  pathological  factors.  A  deficiency  in  the  number  of  colorless  cells 
is  seen  in  starvation  and  in  malnutrition,  and  almost  constantly  in  the 
infectious  diseases  not  associated  with  leucocytosis,  as  tuberculosis,  malaria, 
measles,  influenza,  enteric  fever,  Malta  fever,  and  German  measles.  Low 
leucocyte  counts  are  common  in  pernicious  anaemia,  in  chlorosis,  in  splenic 
anaemia,  and  in  profound  symptomatic  anaemias. 

Myelaemia. — The  appearance  of  myelocytes  in  the  blood,  spoken  of 
as  myelaemia,  points  to  rapid  leucocyte  proliferation  in  the  bone-marrow. 
Myelocytes  are  often  found  in  the  circulation  when  leucocytosis  is  present. 
In  splenomedullary  leukaemia  this  condition  is  most  striking,  in  pernicious 
anaemia,  cholorsis,  lymphatic  leukaemia,  Hodgkin's  disease,  and  in  profound 
secondary  anaemias,  a  small  number  of  myelocytes  is  not  infrequent. 


f 


t 


* 


• 


1.     NEUTROPHILE    LEUCOCYTOSIS.  2.     EOSINOPHILS. 

3.     LYMPHOCYTOSIS.  4.     MYEL/EMIA. 

(lEI8HMAN'8    9TAIm) 


/.     Schmitit 
AHtcnli 


EXAMINATION  OF  THE  BLOOD.  275 

Parasites — Bacteremia. — Bacteria  frequently  gain  access  to  the  cir- 
culation, either  from  an  infected  area  within  the  body  or  from  without. 
Bacteria  are  seldom  found  by  a  microscopical  examination  of  the  fresh 
unstained  blood;  culturing  methods  being  required  to  reveal  their  pres- 
ence. From  a  clinical  view-point  the  demonstration  of  bacteria  in  the 
circulation  may  be  regarded  as  evidence  of  disease.  The  detection  of 
micro-organisms  in  the  blood  is  often  essential  in  establishing  a  diagnosis 
of  septicaemia,  malignant  endocarditis,  puerperal  sepsis,  and  pyaemia.  In 
some  of  the  specific  infectious  diseases  the  exciting  principle  has  been 
isolated  from  the  blood.  In  over  80  per  cent,  of  the  cases  of  enteric  fever, 
Eberth's  bacillus  can  be  recovered  from  the  blood  by  culture  methods. 
The  specific  micro-organisms  of  paratyphoid  fever,  croupous  pneumonia, 
anthrax,  glanders,  leprosy  influenza,  plague,  tuberculosis,  and  Malta  fever 
have  been  isolated  from  the  blood.  In  septicaemia  or  septicopysemia  staph- 
ylococci, streptococci,  and  gonococci  have  been  separated  from  the  blood. 

Animal  Parasites.  —  From  our  present  knowledge  it  is  impossible  to 
fix  a  sharp  dividing  line  separating  some  of  the  lower  vegetable  and  animal 
parasites.  Investigators  seem  to  favor  placing  the  Treponema  pallidum 
and  the  spirochaeta  of  relapsing  fever  among  the  animal  parasites.  For 
a  description  of  the  animal  parasites  found  in  the  blood,  the  reader  is 
referred  to  the  section  which  deals  with  diseases  caused  by  animal  parasites. 

Method  of  Examination  for  Malarial  Parasites. — Fresh,  unstained  blood 
is  more  suitable  for  study  than  stained  blood,  because  it  enables  the 
examiner  to  observe  the  activity  of  the  parasites.  The  most  desirable 
time  for  conducting  the  examination  is  during  the  period  when  pigmented 
forms  are  present.  The  intracellular  pigmented  bodies  are  usually  most 
abundant  about  6  or  8  hours  before  a  paroxysm.  Considerable  experience 
is  necessary  before  the  various  types  can  be  differentiated;  especially  is 
this  true  of  hyaline  unpigmented  forms.  The  skilled  microscopist  must 
often  make  a  prolonged  search  before  parasites  are  detected  in  malarial 
blood.  The  fresh  blood  is  prepared  in  the  usual  manner,  between  a  cover- 
glass  and  slide,  and  the  examination  is  made  with  an  oil-immersion  lens 
with  moderate  illumination.  When  the  examination  of  fresh  blood  is  imprac- 
ticable, dried  specimens  treated  by  one  of  the  different  forms  of  the  Roman- 
ou  <ky  stain  as  variously  modified  by  Leishman  and  others  (Wright,  Hastings) 
constitute  a  satisfactory  means  of  direct  diagnosis.  The  effectual  adminis- 
tration of  quinine  reduces  the  number  of  parasites  and  causes  their  disap- 
pearance from  the  peripheral  circulation.  In  a  suspected  case  the  examination 
of  the  blood  should  precede  the  institution  of  treatment. 


276  MEDICAL  DIAGNOSIS. 


VI. 
THE  EXAMINATION  OF  THE  URINE. 

The  essential  diagnostic  principles  of  urinalysis,  coupled  with  certain 
methods  of  examination  required  for  general  clinical  work,  are  detailed 
in  the  following  section.  Tests  suitable  for  the  general  practitioner  must 
in  the  main  be  simple  and  easily  applied.  The  importance  of  the  findings 
obtained  by  careful  and  systematic  studies  of  the  urine,  when  correctly 
interpreted  and  given  their  proper  place  in  a  symptom-complex,  can  scarcely 
be  overestimated  in  diagnosis.  In  a  considerable  group  of  morbid  states 
the  urinary  picture  is  absolutely  necessary  in  establishing  a  final  diagnosis, 
while  in  a  large  number  of  cases  the  results  of  the  examination  form  a  link 
in  the  chain  of  symptoms  completing  the  diagnosis.  Negative  reports  in 
some  instances  are  essential  for  the  solution  of  certain  clinical  problems. 
For  an  exhaustive  account  of  the  urine,  which  does  not  fall  within  the  scope 
of  this  book,  the  reader  is  referred  to  special  treatises  on  this  subject. 

PHYSICAL    EXAMINATION. 

Amount. — The  daily  standard  for  a  healthy  adult,  as  estimated  by 
different  authorities,  varies  between  900  and  2000  c.c.  Most  observers 
fix  the  amount  between  1000  and  1500  c.c,  although  temporary  oscilla- 
tions beyond  these  limits,  of  slight,  moderate,  or  even  of  an  excessive  degree, 
are  often  physiological.  The  urinary  secretion  is  greater  during  the  day 
than  through  the  night,  more  abundant  in  cold  than  in  hot  weather,  and 
relatively  more  active  in  children  and  infants  than  in  adults.  Polyuria 
depends  in  the  main  on,  (a)  increased  ingestion  of  water,  (b)  heightened 
blood-pressure,  and  (c)  on  increased  activity  of  the  renal  epithelium,  while 
oliguria  results  from  (a)  lessened  consumption  of  water,  (b)  lowered  blood- 
pressure,  and  (c)  impaired  function  of  kidney  epithelium. 

Specific  Gravity. — In  health  the  specific  gravity  ranges  between  1.015 
and  1.025  while  the  daily  output  of  urine  is  within  normal  limits.  In 
general  terms  the  specific  gravity  is  a  fair  index  of  the  bulk  of  solids  elimi- 
nated. An  approximate  estimate  of  the  weight  of  urinary  solids  expressed 
in  grammes  for  a  thousand  cubic  centimetres  of  urine  may  be  determined 
by  multiplying  the  second  and  third  decimal  figures  of  the  specific  gravity 
by  two.  Pathologically,  wide  variations,  as  low  as  1.002  and  as  high  as 
1.040,  are  frequent.  Ranges  above  1.050  are  extremely  uncommon.  The 
volume  of  urine  and  the  specific  gravity  in  the  main  fluctuate  in  an  inverse 
manner;  therefore,  without  a  knowledge  of  the  daily  output  the  density 
has  practically  no  clinical  significance.  A  correct  specific  gravity  determi- 
nation can  only  be  made  from  a  mixed  twenty-four  hours'  sample.  In  dis- 
eases associated  with  polyuria  lowered  ranges  are  the  rule.  A  notable  ex- 
ception is  found  in  the  case  of  diabetes  mellitus,  in  which  the  increased 
density  is  caused  by  the  presence  of  glucose.  A  diminished  volume  of 
urine  of  low  specific  gravity  is  seen  in  a  number  of  chronic  diseases,  and 


EXAMINATION  OF  THE  URINE.  277 

often  in  cases  of  oedema.  Large  urinometers  are  preferable  to  small  instru- 
ments for  measuring  the  specific  gravity,  since  the  divisions  of  the  scale 
can  be  read  with  greater  accuracy.  The  large  amount  of  urine  necessary 
to  float  these  hydrometers  is,  however,  an  objectionable  feature.  This 
may  be  overcome  by  estimating  the  density  with  a  set  of  two  or  three 
pycnometers  of  moderate  size,  each  of  which  represents  a  portion  of  the 
scale.  In  measuring  the  specific  gravity  the  following  precautions  are 
essential  for  accurate  results:  The  hydrometer  should  be  placed  into  cool 
urine,  the  surface  of  which  is  free  from  foam;  the  instrument  should 
not  touch  the  sides  of  the  hydrometer  jar. 

Color. — Normal  urine  owes  its  color  to  urochrome  and  urobilin,  chiefly 
to  the  former,  while  the  tints  of  many  pathological  urines  depend  upon 
such  substances  as  biliary  pigment,  haemoglobin,  methaemoglobin,  haematin, 
haematoporphyrin,  melanin,  indican  and  alkaptone.  After  the  ingestion  of 
iodine,  phenol,  salol,  senna,  santonin,  and  methylene  blue,  the  urine  often 
has  an  abnormal  hue.  The  shade  of  the  color  depends  chiefly  upon  the 
amount  of  urinary  water,  so  that  concentrated  specimens  are  usually  dark, 
while  those  of  low  specific  gravity  are  generally  pale.  An  exception  to  this 
rule  is  noted  in  diabetic  urine,  which  is  light  yellow  or  pale  greenish-yellow, 
of  increased  density  and  of  excessive  quantity.  In  acute  febrile  diseases 
and  pernicious  anaemia  the  urine  is  high  colored,  while  in  chlorosis,  dia- 
betes insipidus,  and  contracted  kidney  it  is  pale.  Bile  pigment  is  respon- 
sible for  dark  yellow,  yellowish-green,  dark  brown,  and  rarely,  black  urine, 
which  on  shaking  develops  a  yellowish  foam;  blood  pigment  stains  the 
urine  bright  red,  dark  red,  reddish-brown,  or  rarely,  black.  Melanotic 
pigment  imparts  a  brown  or  black  appearance  which  generally  develops 
some  time  after  the  urine  is  voided,  but  occasionally  is  noted  in  the  fresh 
specimen.  A  similar  color  occurs  in  alkaptonuria,  which  condition  can  be 
differentiated  from  melanuria  by  testing  with  Fehling's  solution;  the  alkap- 
tone bodies  reduce  the  copper  salt,  while  the  latter  gives  a  negative  reac- 
tion. The  ingestion  of  phenol  and  its  allied  compounds  may  cause  a  green- 
ish-black discoloration,  of  methylene  blue  a  green  or  blue  urine,  of  santonin 
a  yellow,  and  of  rhubarb  an  orange-colored  urine.  A  milky  appearance  is 
noted  in  chyluria  and  at  times  in  phosphaturia  and  pyuria.  The  presence 
of  haematoporphyrin  may  impart  a  dark  red  color. 

Transparency.  —  Normal  urine  immediately  after  being  voided  is 
generally  clear;  on  cooling  it  occasionally  becomes  turbid,  due  to  pre- 
cipitation of  urates  or  phosphates.  Turbidity,  associated  with  a  sediment, 
is  one  of  the  characteristic  features  of  many  abnormal  urines,  and  may 
depend  upon  an  excess  of  urates  or  phosphates,  or  on  the  presence  of 
epithelial  elements,  pus-cells,  red  blood-corpuscles,  chyle,  or  bacteria. 

Odor. — This  property  of  the  urine,  although  of  little  clinical  signifi- 
cance, except  in  a  few  instances,  occasionally  attracts  the  attention  of  the 
p;itient  who  suspects  that  an  abnormal  state  of  the  kidneys  exists.  The 
odor  of  normal  urine  is  sufficiently  familiar  to  require  no  special  description. 
I'tine  decomposed  by  bacterial  growth  within  the  bladder,  or  after  it  has 
been  voided,  emits  an  ammoniacal  stench.  Acetone,  when  present  in  large 
amount,  may  give  the  urine  a  sweetish,  fruit-like  odor.  The  ingestion  of 
turpentine,   terebene,  asparagus,   and   onions   imparts    peculiar  odors. 


278  MEDICAL  DIAGNOSIS. 

Reaction. — A  normal,  mixed  twenty-four  hour  sample  in  nearly  every 
instance  is  acid,  while  individual  specimens  passed  during  the  day  vary 
considerably  in  reaction.  For  clinical  purposes  the  reaction  may  be  deter- 
mined with  litmus  paper.  An  alkaline  reaction  after  a  heavy  meal  is 
attributed  to  the  increased  alkalinity  of  the  blood  during  gastric  digestion. 
The  ingestion  of  food  rich  in  vegetables,  or  the  administration  of  tartaric, 
citric,  or  acetic  acid  lessens  acidity,  or  produces  alkalinity,  while  a  diet 
rich  in  meat  or  the  taking  of  mineral  acids  intensifies  the  acidity.  The 
reaction  of  normal  urine  is  held  to  be  due  to  diacid  phosphate;  Folin, 
however,  contends  that  free  organic  acids  are  in  part  responsible.  The 
total  acidity  of  a  twenty-four  hour  collection  of  healthy  urine  is  equal  to 
from  1.5  to  2.3  grammes  of  hydrochloric  acid.  Alkalinity  is  caused  by 
the  presence  of  alkalies  in  excess  of  acids.  An  amphoteric  reaction  depends 
on  a  balance  existing  between  the  acid  and  basic  equivalent  of  the  urinary 
salts.  Urine  that  has  been  exposed  to  the  air  for  some  time  becomes  alka- 
line from  ammoniacal  decomposition.  Alkaline  urine  is  frequently  seen  in 
cystitis,  but  in  a  number  of  cases  of  bladder  inflammation,  both  acute  and 
chronic,  the  urine  is  acid.  A  strongly  acid  urine  occurs  in  gout,  diabetes, 
rheumatic  fever,  in  some  varieties  of  nephrolithiasis,  in  leukaemia,  in  intes- 
tinal and  stomach  diseases  associated  with  diminished  or  abolished  gastric 
secretion,  in  scurvy,  in  chronic  nephritis,  and  often  in  febrile  states.  Low- 
ered acidity,  and  occasionally  alkalinity,  is  seen  in  anaemia,  notably  per- 
nicious anaemia  and  chlorosis,  following  the  crisis  of  pneumonia,  after 
blood  transfusion  with  saline  solution,  in  haematuria,  and  when  transudates 
are  rapidly  absorbed. 

Sediments.  —  Occasionally  deposits  of  uric  acid,  amorphous  urates, 
carbonates  and  phosphates,  and  invariably  those  consisting  of  pus,  epi- 
thelial and  red  blood-cells,  are  significant  of  morbid  states.  The  presence 
of  a  sediment  of  uric  acid  crystals,  amorphous  urates,  or  phosphates  need 
not,  and  as  a  rule  does  not,  imply  an  increased  output  of  these  salts,  but 
may  depend  on  changes  in  the  reaction  of  the  urine. 

MICROSCOPICAL    EXAMINATION. 

Microscopical  examination  of  sediments  is  of  cardinal  importance  in 
urinalysis.  A  sediment  best  suited  for  this  method  of  study  should  be 
secured  from  a  fresh  specimen  of  urine  by  centrifugalization.  When  the  ex- 
amination cannot  be  made  immediately  after  the  urine  is  voided,  it  is  advis- 
able to  add  an  antiseptic  to  it,  such  as  a  little  powdered  camphor,  a  few  drops 
of  formaldehyde  solution,  or  thymol,  in  order  to  prevent  decomposition. 

Crystalline  and  Amorphous  Substances  Present  in  Acid  Urine. — 
Calcium  Oxalate. — Crystals  of  calcium  oxalate  are  found  in  many  sedi- 
ments and  appear  in  various  sizes,  mostly  in  the  form  of  colorless  octahedra, 
generally  designated  "envelope  crystals,"  sometimes  as  dumb-bell  figures 
and  rarely  as  oval  disks.  These  crystals  are  soluble  in  hydrochloric  acid, 
but  not  in  acetic  acid  or  sodium  hydrate.  Normal  urine  may  contain  these 
crystals,  after  the  eating  of  tomatoes,  asparagus,  garlic,  rhubarb,  or  oranges. 
After  the  ingestion  of  bicarbonate  of  soda,  in  certain  forms  of  gastro- 
intestinal neuroses,  in  jaundice,  in  phthisis,  and  in  diabetes  mellitus,  oxa- 


EXAMINATION  OF  THE  URINE. 


279 


late  crystals  are  sometimes  noted.  Renal  calculi  composed  of  this  substance 
are  not  uncommon.  Oxaluria  can  only  be  regarded  as  pathological  when 
a  chemical  examination  shows  an  increased  quantity  of  oxalic  acid,  provided 
the  factors  responsible  for  its  occurrence  in  health  can  be  excluded. 

Uric  Acid. — This  substance,  as  a  rule,  crystallizes  in  the  form  of  whet- 
stone shaped  crystals,  arranged  singly  or  in  clusters,  and  occasionally  in 
the  form  of  dumb-bell  figures,  or  as  rhombic  plates.  These  crystals  vary 
considerably  in  size,  and  their  color  ranges  from  a  pale  yellow  to  a  dark 
brown.  Urie  acid  crystals  dissolve  in  a  sodium  hydrate  solution,  and  when 
this  test  is  followed  by  the  addition  of  hydrochloric  acid  to  the  alkaline 
solution,  rhombic  plates  appear.  Uric  acid  crystals  are  frequently  seen  in 
the  urine  when  the  uric  acid  output  is  normal  or  even  decreased,  since  this 
substance  is  more  readily  soluble  in  warm  than  in  cold  solution.  Urinary 
inspissation  is  another  factor  which  determines  precipitation.    In  leukaemia, 


O.    v,  - 


' . 


Fig.  107. — Calcium  oxalate  crystals. 


Fig.  1CS.— Uric  acid  crystals. 


and  during  or  immediately  following  acute  gout,  the  urine  contains  an 
excess  of  uric  acid,  and  may  reveal  an  abundant  precipitate  of  these  crys- 
tals (brick-dust  sediment).  Calculi  formed  of  uric  acid  are  among  the  most 
common  renal  concretions.  When  amorphous  granules  of  sodium  and 
potassium  urate  occur  in  the  urine  in  abundance,  they  impart  a  turbidity 
to  it,  which  is  often  associated  with  a  light  yellow  or  pink  sediment.  This 
precipitate  disappears  upon  heating  the  urine  to  a  temperature  of  50°  C; 
on  the  addition  of  hydrochloric  acid  to  the  urine,  amorphous  urates  are 
converted  into  uric  acid  crystals.  Amorphous  sediments  of  urates  are 
frequently  present  in  scanty,  concentrated  urines,  such  as  occur  in  fevers. 
Calcium  sulphate  is  seen  in  the  form  of  long,  transparent  colorless 
needles,  or  elongated  platelets,  arranged  singly  or  in  crystalline  masses. 
They  are  insoluble  in  ammonia,  acetic  acid,  and  alcohol.  Von  Jaksch  found 
these  crystals  in  association  with  triple  phosphates  and  calcium  carbonate 
in  the  urine  of  a  patienl  who  showed  a  tendency  to  calculus  formation. 
No  special  clinical  significance  has  as  yet  bee;:  attached  to  ihe  presence 
of  these  crystals. 


280 


MEDICAL  DIAGNOSIS. 


Hippuric  acid  occurs  as  rhombic  prisms  or  slender  needles  arranged 
separately  or  in  clusters.  These  crystals  are  soluble  in  ammonia  and 
insoluble  in  hydrochloric  acid.  They  have  been  noted,  though  very  infre- 
quently, in  febrile  diseases,  in  diabetes,  and  after  the  ingestion  of  benzoic 
acid,  salicylic  acid,  cranberries,  mulberries,  blueberries,  and  prunes. 

Bilirubin  is  found  as  fine  needles  arranged  in  clusters  or  rhombic 
plates  having  a  yellow  or  ruby  color,  or  as  an  amorphous  substance.  This 
sediment  is  soluble  in  sodium  hydrate  and  chloroform;  on  treating  the 
crystals  with  nitric  acid  a  green  color  appears  about  them.  Von  Jaksch 
contends  that  the  presence  of  ciystals  of  bilirubin  in  the  urine,  as  a  rule, 
points  to  antecedent  hemorrhage  into  the  urinary  tract  or  to  the  rupture 
of  an  abscess.  Their  presence,  either  free  or  imbedded  in  cells  or  tube- 
casts,  has  been  recorded  in  acute  nephritis,  chronic  interstitial  nephritis, 
amyloid  kidney,  jaundice,  acute   yellow  atrophy  of  the  liver,  hepatic  cir- 


<§0     o 


Fig.  109. — Leucin  spheres  and  tyrosin  crystals. 


Fig.  110. — Cystin  crystals. 


rhosis,   phosphorous  poisoning,   carcinoma  of  the   bladder,   and  after  the 
rupture  of  a  suppurating  hydatid  cyst  into  the  urinary  tract. 

Leucin  and  Tyrosin. — These  substances  are  never  found  in  normal 
urine.  They  are  generally  held  in  solution  unless  present  in  considerable 
quantities,  when  they  separate  in  a  crystalline  form.  Their  precipitation 
can  be  brought  about  by  treating  the  urine  with  an  excess  of  basic  plumbic 
acetate;  then  filtering;  and  to  filtrate  hydrogen  sulphide  is  added  to  remove 
the  excess  of  lead  acetate.  The  filtrate  is  then  evaporated  to  a  small  volume. 
Absolute  alcohol  is  used  to  remove  traces  of  urea.  The  insoluble  residue 
is  finally  extracted  with  alcohol  containing  a  little  ammonia.  Leucin  and 
tyrosin  will  precipitate  in  this  concentrated  solution.  Leucin  presents  the 
appearance  of  spheres  of  varying  sizes,  sometimes  termed  "leucin  balls.'* 
These  spheres  have  a  brown  color  and  show  delicate  lines  radiating  from 
their  centre  to  the  periphery.  Leucin  spheres  are  insoluble  in  ether. 
Tyrosin  crystals  are  noted  in  the  form  of  slender  needles,  frequently 
grouped  in  bundles.  They  dissolve  in  ammonia  and  hydrochloric  acid, 
but    are   insoluble   in  acetic   acid.      Leucin  and  tyrosin  occurring    mostly 


EXAMINATION  OF  THE  URINE. 


281 


together  have  been  observed  almost  constantly  in  acute  yellow  atrophy 
of  the  liver,  phosphorous  poisoning,  and  Weil's  disease,  occasionally 
in  catarrhal  jaundice,  cholelithiasis,  cirrhosis  and  cancer  of  the  liver, 
enteric  fever,  gout,  and  diabetes,  and  rarely  in  a  limited  number  of 
other    conditions. 

Xanthin  is  found  in  the  form  of  colorless  crystals  resembling  those  of 
uric  acid  in  outline.  They  are  soluble  in  ammonia.  These  crystals  are 
rare  ingredients  of  urinary  sediments;  calculi  consisting  of  xanthin  have 
been  found  by  some  investigators. 

Cystin  crystals  are  six-sided  colorless  plates,  which  are  soluble  in 
ammonia  and  insoluble  in  acetic  acid  and  water.  Von  Jaksch  recommends 
the  following  microchemical  test  for  their  detection:  A  drop  of  hydrochloric 
acid  is  added  to  the  urinary  sediment.  AYhen  the  acid  comes  in  contact 
with    cystin,  there  develop   prismatic    crystals  (hydrochlorate  of   cystin) 


Fig.  111. — Triple  phosphate  crystal* 


Fig.  112. — Neutral  calcium  phosphate  cry-tals. 


which  are  grouped  in  masses  suggesting  a  rosette  form.  Cystinuria  is  a 
rare  condition.  In  some  cases  it  is  unattended  with  symptoms,  while  in* 
others  it  is  responsible  for  calculus  formation. 

Soaps  of  lime  and  magnesia  consist  of  needles  arranged  in  bundles  or 
sheaves,  sometimes  radiating  from  a  central  point  forming  a  sphere.  They 
resemble  tyrosin  crystals  in  form  and  arrangement.  These  crystals  are 
rarely  found.    They  have  been  noted  in  septicaemia. 

Fat  globules  can  be  recognized  by  their  highly  refractive  appearance 
and  solubility  in  ether.  Among  the  conditions  in  which  lipuria  is  seen, 
may  be  mentioned,  acute  and  chronic  parenchymatous  nephritis,  diabetes 
mellitus,  bone  disease  and  injury,  chyluria,  phosphorus  poisoning,  and 
certain  diseases  of  the  liver  and  pancreas. 

Crystalline  and  Amorphous  Substances  found  in  Alkaline  Urine — 
Ammoniomagnesium  phosphate  or  triple  phosphate  crystals  are  color- 
less and  vary  considerably  in  size  and  appearance.  In  their  most  char- 
acteristic form  they  occur  as  the  so-called  "coffin-lid"  crystals;  others 
resemble  fern  Leaves  in  outline,  while  some  are  arranged  in  the  shape  of 


282 


MEDICAL  DIAGNOSIS. 


the  letter  "X."  Triple  phosphate  crystals  are  found  in  association  with 
amorphous  deposits  of  phosphates,  carbonates,  and  at  times  with  ammo- 
nium urate. 

Neutral  calcium  phosphate  occurs  in  alkaline,  faintly  acid,  or 
amphoteric  urine  in  the  form  of  sheets  or  needle-like  crystals,  the  latter 
being  arranged  singly  or  in  masses  forming  dumb-bell  or  star-shaped 
figures.     These  bodies  are  soluble  in  acetic  -acid. 

Neutral  magnesium  phosphate  crystals  are  colorless,  refractile,  elon- 
gated plates  with  irregular  or  bevelled  edges;  they  are  soluble  in  acetic  acid. 

Calcium  carbonate  crystals  are  found  in  alkaline  urine  associated 
with  amorphous  carbonates.  They  are  dumb-bell  shaped  bodies  which 
dissolve  in  acetic  acid  with  the  liberation  of  gas. 

Amorphous  phosphates  of  calcium  and  magnesium  and  amorphous 
carbonates  are  of  common  occurrence  in  alkaline  urine.     The  addition 


Fig.  113. — Ammonium  urate  crystals. 


Fig.  114. — Cholesterin  crystals. 


of  a  fixed  alkali  to  urine  will  precipitate  amorphous  phosphates  and  car- 
bonates. On  heating  urine  having  a  low  acid  or  alkaline  reaction,  a  white 
cloud  similar  to  that  produced  by  albumin  appears  which  consists  of 
phosphates  or  carbonates.  On  the  addition  of  acetic  acid,  phosphates 
and  carbonates  are  dissolved.  The  solution  of  the  latter  is  attended  with 
the  .  evolution  of  gas.  Amorphous  phosphates  or  carbonates  are  often 
responsible  for  a  turbid  urine  with  a  heavy  sediment.  Microscopically, 
these  bodies  appear  as  colorless,  coarse  granules,  which  are  soluble  in  acetic 
acid.  Phosphatic  sediments  are  occasionally  symptomatic  of  certain 
types  of  dyspepsia,  of  neurasthenia,  of  diseases  associated  with  marked 
gastric  acidity,  and  of  some  cases  of  cystitis.  A  deposit  of  phosphates 
does  not  of  itself  indicate  an  increased  output  of  phosphoric  acid;  this  can 
only  be  determined  by  quantitative  analysis. 

Ammonium  biurate  appears  as  dark  brown  spheroidal  bodies  from  the 
surface  of  which  spicules  project,  the  so-called  " thorn-apple "  or  "hedge- 
hog "  crystals,  and  in  the  form  of  coarse  yellow  needles  grouped  in  clusters. 
Ammonia  biurate  may  be  associated  with  triple  and  amorphous  phosphates. 


EXAMINATION  OF  THE  URINE. 


283 


Acetic  acid  will  cause  solution  of  these  crystals  with  the  formation  of  uric 
acid.  Ammoniacal  fermentation  of  the  urine,  occurring  in  the  bladder  or 
after  it  has  been  voided,  is  responsible  for  the  precipitation  of  ammonium 
biurate. 

Cholesterin  crystals  occur  as  colorless  thin  plates.  They  are  rare 
constituents  of  urinary  sediment  and  have  been  observed  in  hydatid  cystic 
kidney,  pyonephrosis,  hydronephrosis,  and  cystitis. 

Indigo,  a  rare  ingredient  of  the  urinary  sediments,  is  found  in  the 
form  of  a  blue  crystalline  body  consisting  of  needles  grouped  in  a  stellate 
manner  or  as  rhombic  plates,  and  also  as  bluish  amorphous  granules. 
The  amorphous  material  is  not  infrequently  present  in  decomposing  urine. 
Indigo  is  a  rare  constituent  of  urinary  calculi. 

Cellular  Deposits.  —  Epithelial  Cells. — Epithelial  cells  in  small 
numbers,  not  sufficient  to  impart  a  sediment  or  cloudiness  to  the  urine, 
can  be  found  in  every  speci- 
men. In  many  instances 
their  number  is  so  large  as 
to  justify  a  diagnosis  of  an 
inflammatory,  atrophic,  or 
degenerative  lesion  involv- 
ing the  genito-urinary  tract. 
The  predominance  of  one  or 
several  of  the  types  of  epi- 
thelial elements,  unless  cor- 
related with  other  clinical 
data,  has  little  significance. 
It  is  impossible  to  locate 
definitely  a  lesion  of  the 
genito-urinary  tract  from  the 
morphological  characters  of 
epithelium  alone.  This  diffi- 
culty is  apparent  when  we 
consider,    (1)     similarity    of 

many  of  the  cells  of  different  parts  of  the  tract,  notably  those  derived 
from  the  pelvis  of  the  kidney,  ureters,  and  bladder,  (2)  alterations  in  the 
shape  of  these  delicate  formations  due  to  the  action  of  the  urine,  and  (3) 
the  influence  exerted  on  these  cells  by  morbific  factors,  such  as  necrosis, 
pressure,  etc.  Therefore,  little  importance  should  be  attached  to  their 
histological  structure.  Round  cells,  having  a  relatively  large  nucleus,  are 
derived  from  the  tubular  structures  of  the  kidney  and  the  deeper  layers 
of  the  renal  pelvis.  "When  casts  are  beset  with  round  cells  it  points  to  a 
renal  origin  of  I  his  epii  helium.  An  abundance  of  round  cells  in  the  absence 
of  casts,  especially  when  pus-cells  and  subjective  symptoms  pointing  to 
pyelitis  are  present,  is  suggestive  of  origin  from  the  renal  pelvis.  This 
opinion  is  strengthened  by  the  presence  of  polygonal  and  conical  cells. 
some  of  which  have  a  tail-like  elongation  of  their  protoplasm;  these  cells 
are  often  arranged  in  a  stratified  manner.  Hound  cells  arc  also  derived 
from  the  male  urethra,  while  small  conical  and  polygonal  cells  originate 
in  the  superficial  layers  of  the  pelvis  of  the  kidney.     Cylindrical  cells  with 


Fig.  115. — Epithelial  cells,  a,  flattened  cells;  6,  conical  cells 
with  tail-like  prolongations;  c,  round  and  polygonal  cells;  d, 
degenerated  cells. 


284  MEDICAL  DIAGNOSIS. 

bluntly  pointed  ends  are  found  in  the  superficial  layers  of  the  male  urethra. 
Flattened,  oval  or  circular,  or  polygonal  cells  line  the  superficial  layers  of 
the  ureter,  bladder,  prepuce,  fossa  navicularis,  and  vagina.  Large  squa- 
mous cells  are  generally  derived  from  the  vagina  or  prepuce.  Protoplasmic 
degeneration  of  the  epithelial  cells  is  extremely  common.  A  final  diagnosis 
should  never  depend  on  the  characters  of  the  epithelia  in  the  absence  of 
clinical  findings. 

Leucocytes. — A  careful  search  in  every  normal  or  morbid  specimen 
of  urine  will  reveal  a  few  leucocytes.  The  action  of  the  urine  upon  these 
cells  causes  alterations  in  their  structure.  In  acid  urine  they  have  a  distinct 
nucleus,  while  in  alkaline  urine  their  protoplasm  is  swollen  and  cloudy, 
obscuring  the  nucleus.  By  treating  a  specimen  of  urine  having  a  weakly 
acid  or  alkaline  reaction  with  acetic  acid,  the  nuclear  outline  becomes  shaiply 
marked.    The  leucocytes  stain  a  mahogany  brown  with  a  solution  of  iodo- 

potassic  iodide  (glycogen  reaction), 
while  epithelial  cells  are  tinted  a 
light  yellow  with  this  reagent.  Pus- 
cells  in  considerable  or  large  numbers 
frequently  indicate  inflammatory 
disease  of  some  part  of  the  genito- 
urinary tract.  They  occur  in  renal 
hyperemia,  nephritis,  abscess  and 
tuberculosis  of  the  kidney,  pyelitis, 
urethritis,  cystitis,  prostatitis,  epi- 
didymitis, and  orchitis.  A  leucor- 
rhceal  discharge  is  a  common  cause  of 
pyuria.  Urine  containing  many  pus- 
corpuscles  generally  gives  a  positive 
reaction  for  albumin.  Renal  and  ex- 
trarenal albuminuria  may  coexist. 

Fig.  116.— Red  blood-cells  and  leucocytes.  RED  BLOOD-CELLS. — Hematuria, 

or  the  presence  of  red  corpuscles  in 
the  urine,  is  always  pathological  except  during  menstruation.  In  cer- 
tain uterine  diseases  attended  with  bloody  discharge  some  of  the  eryth- 
rocytes may  be  washed  into  the  urine.  A  microscopic  inspection  serves 
to  recognize  red  blood-cells  in  almost  every  instance,  so  that  chemical 
tests  for  their  detection  are  rarely  required.  In  some  urines  the  red  cells 
are  unaltered,  while  in  others  changes  in  their  structure  are  found,  such  as 
decided  shrinkage  of  the  cell,  or  crenation,  or  they  may  be  partially  or 
completely  decolorized,  and  appear  as  pale  yellow  disks  or  as  faintly  out- 
lined rings  (phantom  corpuscles).  The  quantity  of  blood  may  be  sufficient 
to  tinge  the  urine  pale  or  dark  red,  but  in  many  cases  the  amount  is  so 
small  that  the  microscopic  test  is  essential  in  the  diagnosis  of  hematuria. 
When  the  erythrocytes  are  intimately  mixed  with  the  urine,  this  suggests 
a  hemorrhage  in  the  kidneys,  renal  pelvis,  or  ureters.  The  presence  of 
dehaemoglobinized  corpuscles  is  noted  in  kidney  lesions,  such  as  congestion 
and  inflammation.  Unaltered  blood  or  blood-tinged  urine  passed  at  the 
beginning  of  micturition  is  of  urethral  origin;  on  the  other  hand,  when 
blood  appears  at  the  end  of  urination,  its  source  is  generally  the  neck  of 


O     p-;.. 

• 

am 

) 

* 

EXAMINATION  OF  THE  URINE.  285 

the  bladder.  Bleeding  may  cause  coagula  of  certain  shapes;  cylindrical 
clots  of  large  size  suggest  urethral  hemorrhage,  those  of  small  diameter 
may  indicate  ureteral  hemorrhage,  while  irregular  clots  often  form  in  the 
bladder.  Neither  the  morphological  characters  of  red  blood-cells  nor  the 
size  and  outline  of  clot  can  be  relied  upon  to  definitely  determine  the 
site  of  a  hemorrhage,  unless  these  findings  are  supported  by  other  clinical 
data.  The  use  of  the  cystoscope,  urethral  and  ureteral  catherization,  and 
examination  with  X-rays,  especially  for  renal  calculus,  afford  valuable 
adjuncts  in  the  diagnosis  of  hematuria.  An  albumin  reaction  is  invariably 
obtained  when  red  blood-cells  are  abundant  in  the  urine,  but  when  only 
small  numbers  exist,  a  negative  test  is  the  rule.  The  quantity  of  albumin 
is  proportionate  to  the  amount  of  blood. 

Tube-casts. — These  are  cylindrical  bodies  moulded  in  the  uriniferous 
tubules.  Their  structure  is  variable,  and  may  consist  of  a  hyaline  or  waxy 
material,  of  cellular  bodies,  of  granular  elements,  of  fat  globules,  and  in 
rare  instances  of  bacteria  or  of  amorphous  substances. 

Hyaline  Casts. — These,  by  far  the  most  common,  are  slightly  refrac- 
tile,  transparent,  of  regular  outline,  with  rounded  ends.  They  are  invisible 
in  a  brightly  illuminated  field  on  the  microscope,  so  that  it  is  necessary 
to  cut  off  much  of  the  reflected  light  with  the  iris  diaphragm  in  order  to 
bring  out  their  outline.  Epithelial  cells,  leucocytes,  red  blood-corpuscles, 
and  granules  frequently  beset  these  casts,  and,  indeed,  it  is  not  uncommon 
to  find  adherent  cells  or  granules  so  numerous  that  the  hyaline  material 
is  obscured.  Casts  covered  with  granules  are  termed  hyalogranular.  This 
appearance  may  make  it  impossible  to  distinguish  hyaline  casts  from  those 
composed  principally  of  granules.  Clinically,  however,  the  significance  of 
hyaline  casts  coated  with  granules -and  those  composed  wholly  or  mostly  of 
granules  is  identical.  It  should  be  remembered  that  a  sharp  distinction  can- 
not be  drawn  between  these  forms.    Hyaline  casts  are  soluble  in  acetic  acid. 

Waxy  casts  appear  as  highly  retractile,  sharply  defined,  colorless 
or  yellowish  cylinders,  showing  a  tendency  to  transverse  fragmentation. 
Like  hyaline  casts  they  may  be  studded  with  cells  or  granules.  They 
may  exhibit  an  amyloid  reaction,  but  this  is  no  criterion  that  lardaceous 
renal  disease  exists,  but,  on  the  contrary,  amyloid  disease  of  the  kidney  is, 
as  a  rule,  not  associated  with  easts  giving  this  reaction.  Not  infrequently, 
casts  are  observed  that  cannot  be  definitely  classified  as  belonging  to  the 
waxy  or  hyaline  varieties. 

Granular  casts  are  composed  of  fine  or  coarse  granules.  Cells  form- 
ing leucocytic  or  epithelial  casts  may  show  a  decided  granular  protoplasm, 
so  that  it  becomes  difficult  to  distinguish  their  outline;  these  types  consti- 
tute border  line  varieties  between  cellular  and  granular  casts.  Clinically, 
this  is  of  little  moment,  since  the  granular  or  fatty  casts  represent  products 
of  degenerated  cells.     Acetic  acid  dissolves  granular  casts. 

Fatty  CASTS  consist  of  fat  globules  derived  from  degenerated  cells. 
Ether  dissolves  fatty  casts. 

Epithelial  casts  are  made  up  of  renal  epithelial  cells,  many  of  which 
present   degenerative  changes.     These  casts  may  have  tubular  form. 

Leucocytic  casts  consist  of  white  blood-cells.  They  are  generally 
recognized  at  a  glance,  but  should  uncertainty  arise  as  to  the  character  of 


286  MEDICAL  DIAGNOSIS. 

the  cells  forming  these  cylinders,  this  doubt  can  be  settled  by  treating  the 
specimen  with  a  droplet  of  acetic  acid,  which  clarifies  the  protoplasm  of 
the  leucocytes  and  causes  the  nucleus  to  become  distinct. 


J 

4 

9 

■ 

I 

z 

5 

6 

7 

14 

8 

10 

II 

12 

13 

15 

ib 

17  a 

Fig.  117. — Tube-casts  1,  2,  3,  5,  hyaline  casts;  4.  6,  hyaline  casts  beset  with  epithelial  cells; 
7,  hyaline  cast — one  end  of  which  is  coated  with  fine  granules;  8.  hyaline  cast  beset  with  leucocytes; 
9,  finely  granular  cast;  10,  coarsely  granular  cast;  11,  12,  13,  waxy  casts;  14,  fatty  cast;  15,  16, 
epithelial  casts;    17,  blood-cast;    18,  leucocytic   cast. 

Blood-casts  consist  of  erythrocytes,  many  of  which  may  be  altered 
by  crenation  or  dehsemoglobinization.  Pus-  and  blood-casts  are  rarely 
encountered.    Casts  formed  of  haemoglobin,  of  bacteria,  or  of  urates  are  rare. 

Cylindroids  are  of  two  forms;  one  variety  appears  as  long  twisted 
or  curved  ribbon-like  structures,  composed  of  mucus,  and  therefore  insolu- 
ble in  acetic  acid.     This  cylindroid  is  readily  distinguished  from  true  hya- 


EXAMINATION  OF  THE  URINE.  287 

line  casts,  because  of  its  length  and  flattened  appearance.    A  second  group 
consists  of  elongated  cylindrical  bodies.     They  show  considerable  varia- 
tion in  their  short  diameter,  and  are  composed  of  a  hyaline  material.    This 
cylindroid  often  tapers  into  a  long  thread-like  tail.     Some  of  the  latter 
variety  closely  resemble  hyaline  casts,  but  can  generally  be  distinguished 
from  glassy  casts  by  their  irregular  diameter.     The  material  composing 
the  latter  type  is  soluble  in  acetic  acid.     Some  authorities  contend  that 
this  form  of  cylindroid  has  the  same  clinical  significance  as  the  hyaline 
cast.     The  mucous   cylindroids  are    in  the  main  formed   in  the  bladder. 
Clinical  Significance  of  Tube=casts. — Tube-casts,   especially   of    the 
hyaline  variety,  are  often 
found   in    the    urine    of 
morbid  states  and  occa- 
sionally   of    apparently 

healthy  persons.     Some  / 

observers  maintain  that 
their  presence  in  the 
urine  of  so-called  healthy 
pel  sons  can  be  explained 

by    temporary     circula-  2  j 

tory   disturbances,   such  j 

as  result  from  violent 
physical  exercise  or  from 
overstimulation,  as  with 
alcohol.  These  circula- 
tory derangements,  al- 
though of  a  temporary 
nature,  cannot  be  re- 
garded as  strictly  physi- 
ological; therefore,  the  3 
presence  of  casts  under 
such  circumstances  re- 
flects an  abnormality  of  2 
the  renal  function.    The 

finding    Of    Casts    OVer     a  Fig.  118.— rylimlroids.     I,  Cylin<lroi<l<=  resemhlinp  hyaline  tnhe- 

lnnrr         iw»virwl         rmnnrollir  casts    2,   cvlintlroids  stippled    with  granules;    3,   ribbon-like  mucous 

long  penou  gi .in  lany  cyiin<Jroids;  4,  spiral  form  of  cylindroid.— Modified  from  Emerson. 
warrants  a  diagnosis  of 

structural  changes  in  the  kidneys.  The  number  of  casts  present  in  a  speci- 
men of  urine  is  sometimes  an  index  of  the  extent  or  severity  of  renal  involve- 
ment.  In  acute  diffuse  nephritis  their  number  is  generally  large,  in  chronic 
parenchymatous  nephritis  they  are  usually  fairly  abundant,  while  in  the 
interstitial  form  only  a  small  number  is  noted.  In  passive  renal  conges- 
tion, amyloid  disease,  and  in  tlu.  tie  generations  attending  febrile  diseases, 
casts  are  generally  few  in  number,  but  occasionally  plentiful.  The  size  of 
casts  varies  considerably.  Large  cylinders  at  times  exceed  l  mm.  in  length. 
The  size  of  tube-casts  has  no  special  diagnostic  significance.  The  predomi- 
nance of  one  or  several  varieties  of  casts  may  be  of  value  in  deciding 
the  character  of  a  renal  lesion.  Hyaline  casts  do  not  signify  any  special 
morbid  change,  as  they  occur  under  a  variety  of   circumstances.     Often 


288  MEDICAL  DIAGNOSIS. 

they  appear  when  there  is  only  a  slight  functional  derangement  of  -the 
kidneys,  but  they  are  invariably  present  in  organic  renal  disease.  Waxy, 
granular,  epithelial,  and  fatty  casts  point  to  degeneration  of  the  renal 
parenchyma,  while  pus-casts  may  indicate  purulent  kidney  disease.  Blood- 
casts  signify  hemorrhage. 

Spermatozoa  and  Testicular  Casts. — Spermatozoa  are  found  in  the 
urine  after  coitus  pollution,  and  rarely  after  convulsions.  The  urine  which 
contains  spermatozoa  occasionally  reveals  testicular  casts.  These  casts 
closely  resemble  renal  casts.  They  can,  however,  be  distinguished  from  the 
latter,  since  they  occur  only  in  the  first  part  of  the  urine  voided,  while  renal 
casts  are  present  in  the  entire  specimen.  Their  recognition  depends  mainly 
upon  the  finding  of  spermatozoa  with  these  casts  in  the  first  urine  of  a  two- 
glass  test,  and  an  absence  of  both  of  these  elements  in  the  second  specimen 
of  urine. 

Irregular  shreds  and  ribbon-like  threads  (Tripperfaden)  are  seen  with- 
out magnification  in  the  urine  after  acute  gonorrhoea  and  in  chronic  ure- 
thritis. They  consist  of  shreds  of  coagulated  mucus,  to  which  are  generally 
adherent  leucocytes  and  epithelial  cells. 

Bacteria;  Animal  Parasites. — Bacteria. — The  presence  of  bacteria  in 
abnormal  urine  depends  upon  (1)  contamination  of  urine  after  it  is  voided, 
(2)  existence  of  infectious  lesions  of  the  genito-urinary  tract  or  communi- 
cating with  it,  and  (3)  elimination  of  bacteria  from  the  blood  by  the  kidneys. 
In  large  numbers  bacteria  impart  turbidity  to  the  urine,  which  does  not 
clear  up  completely  by  centrifugating  or  by  passing  the  urine  through 
filter-paper. 

The  Micrococcus  urea?  is  considered  responsible  for  ammoniacal  fer- 
mentation. The  colon  bacillus,  tubercle  bacillus,  typhoid  and  paratyphoid 
bacillus,  plague  bacillus,  ray  fungus,  sarcime  and  moulds  are  the  commoner 
micro-organisms  found  in  pathological  urine.  The  typhoid  bacillus,  which 
is  eliminated  by  the  kidney  in  every  case  of  enteric  fever,  is  occasionally  the 
exciting  factor  of  inflammatory  disease  of  the  bladder  and  renal  pelvis. 

Tubercle  bacilli  in  the  urine  may  indicate  a  tuberculous  focus  in  the 
urinary  tract.  Their  elimination  by  the  kidneys  from  the  blood  in  the 
absence  of  genito-urinary  tuberculosis  has  been  suggasted. 

Watson's  method  for  the  demonstration  of  tubercle  bacilli  in  the  urine 
is  very  satisfactory.1  Technic. — Irrigate  the  glans  penis  and  urethra  with 
sterile  water  and  have  the  patient  void  in  three  glasses.  The  last  glass  is  a 
250  c.c.  conical  shaped  sedimenting  glass  which  is  capable  of  being  fitted  in 
a  high  powered  laboratory  centrifuge.  If  unable  to  secure  the  desired 
amount — 200  c.c. — the  specimen  is  set  aside  under  sterile  conditions  and 
the  process  repeated  as  often  as  required.  The  urine  may  be  secured  by 
catheter  and  the  entire  quantity  used. 

Centrifuge  the  specimen  for  five  minutes'.  If  much  sediment  is  present 
add  5  c.c.  of  antiformin  and  thoroughly  mix.  The  specimen  is  again  cen- 
trifuged — thirty  to  forty-five  minutes — after  which  the  supernatant  fluid  is 
decanted  off  and  the  sediment  used  for  preparing  glass  slides.  The  slides* 
are  dried  in  air  and  fixed  by  heat.     If  the  slides  seem  too  thick,  place  in  a 

i  Watson,  Am.  Jour.  Med.  Sc,  Nov.  191S. 


EXAMINATION  OF  THE  URINE.  289 

5  per  cent,  acid  (HC1)  alcohol  mixture  for  two  minutes.  The  slides  are 
now  submerged  in  a  solution  of  carbol  fuchsin  for  ten  minutes.  The  solu- 
tion is  heated  until  it  steams.  "Wash  slides  with  water,  place  in  a  2  per  cent. 
acid  (HC1)  alcohol  solution  until  completely  decolorized,  and  counterstain 
with  Loeffler's  methylene  blue. 

The  smegma  bacillus  which  exists  in  the  secretions  of  the  external 
genitals  is  differentiated  from  the  tubercle  bacillus  by  the  acid  alcohol 
method  or  by  Pappenheim's  stain. 

Yeast  cells  found  in  diabetic  urine  may  give  rise  to  pneumaturia. 

Animal  Parasites. — The  Trichomonas  vaginalis  is  rarely  noted  and 
its  presence  is  probably  dependent  upon  contamination  of  the  urine  with 
a  vulvovaginal  discharge  containing  this  parasite.  Ova  of  the  Distoma 
haematobium  are  sometimes  seen  in  the  urine  when  the  adult  worm  resides 
in  the  mucous  membrane  of  the  renal  passages.  Distomiasis  is  essentially 
a  tropical  disease  which  is  occasionally  responsible  for  haematuria.  Filarial 
embryos  have  been  found  in  certain  cases  of  tropical  hematuria.  Echino- 
coccus  hooklets  or  fragments  of  cysts  may  be  present  in  eases  of  hydatid 
disease  of  the  urinary  system.  There  are  a  few  instances  on  record  in 
which  the  Eustrongylus  gigas  was  noted  in  the  urine. 

Calculi. — Urinary  calculi  of  renal  and  vesical  origin  vary  in  size  and 
outline.  Stones  small  enough  to  pass  through  the  urinary  passages  are  more 
common  than  the  large  calculi  found  in  the  renal  pelvis  or  bladder. 

Uric  acid  stones  vary  in  size  from  that  of  a  grain  of  sand  to  concre- 
tions large  enough  to  fill  up  the  renal  pelvis.  These  calculi  are  reddish- 
brown  or  dark  gray,  very  dense,  have  a  smooth  or  slightly  roughened  sur- 
face, dissolve  in  alkalies,  and,  when  treated  with  sodium  hydrate,  generate 
ammonia.  They  give  murexide  test.  Sometimes  calcium  oxalate  is  present 
in  uric  acid  concretions.  Ammonium  urate  stones  have  a  waxy  consist- 
ence, give  the  murexide  test  and  liberate  ammonia  when  treated  with  sodium 
hydrate.  These  calculi  are  rare. '  At  times  they  are  found  in  adults,  and 
are  occasionally  discovered  in  the  new-born.  Calcium  oxalate  stones  are 
responsible  for  severe  attacks  of  renal  eolio  and  hematuria.  These  calculi 
are  very  hard,  their  surface  is  generally  irregular,  often  showing  sharp 
projections,  and  their  color  is  dark  gray  or  black.  Hydrochloric  acid  dis- 
solves them,  and  acetic  acid  will  also  cause  solution  when  added  to  the 
powdered  stone.  Phosphate  stones  have  a  soft  texture,  are  white  or  pale 
yellow,  and  have  a  rough  surface.  They  are  soluble  in  acetic  acid  without 
gas  formation.  They  are  formed  in  the  bladder  much  more  frequently  than 
in  the  renal  pelvis.  Cystin"  stones  have  a  wax-like  consistency,;  are  white  or 
yellowish  in  color,  dissolve  in  ammonia,  and  give  the  reaction  for  cystin. 
They  are  of  rare  occurrence.  XaNthtn  stones  are  hard,  of  a  white  or  yel- 
lowish-brown  color,  and  dissolve  in  ammonia.  Indigo  stones  have  a  blue  or 
bluish-gray  color.  Xanthiu  and  indigo  calculi  are  extremely  rare.  Calcium 
cabsonate  stones  are  white,  have  a  chalk-like  consistency,  and  are  soluble 
in  acetic  acid  with  gas  formation.  Stones  consisting  of  fattv  acids  and 
cholesterin  have  been  recorded  in  a  few  instances. 

Tumor  fragments  from  carcinoma  or  sarcoma  of  the  urinary  tracl  are 
rarely  presenl  in  the  urine.  Fecal  matter  has  been  found  in  the  urine  in 
ts  of  enterovesical  fistula. 

10 


290 


MEDICAL  DIAGNOSIS. 


CHEMICAL  EXAMINATION. 

Nitrogenous  Bodies. — The  normal  amount  of  nitrogen  eliminated  by  the 
kidneys  per  day  varies  between  10  and  16  grammes.  It  may  be  reduced 
to  5  or  6  grammes  on  a  vegetable  diet.  Nitrogen,  the  best  index  of  proteid 
metabolism,  is  principally  eliminated  in  the  form  of  urea,  and  to  some 
extent  as  ammonia,  uric  acid,  and  extractives.  Hammarsten's  estimation 
of  the  percentage  of  nitrogen  excreted  in  the  principal  nitrogenous  bodies 
is  as  follows : 


Urea 

NH3 

Uric  acid. . 
Extractives 


Adults,  per  cent. 


Infauts,  per  cent. 


84  to  91 
2  to  5 
1  to  3 
7  to  12 


73  to  76 
7.8  to  9.6 
3  to  8.5 
7.3  to  14.7 


/Z> 


Nitrogen  is  increased  by  a  rich  proteid  diet,  active  exercise,  in  fevers, 
in  cachexia,  in  diabetes,  in  poisoning  by  arsenic,  antimony,  phosphorus, 
and  certain  organic  poisons,  after  hemorrhage,  in 
dyspepsia,  during  the  resolution  stage  of  pneu- 
monia, and  from  the  absorption  of  exudates  and 
transudates.  It  is  lowered  from  lack  of  exercise, 
by  a  vegetable  diet  or  one  containing  much  carbo- 
hydrate, during  the  convalescence  of  fevers,  in  per- 
sons gaining  weight  rapidly,  during  pregnancy, 
during  the  formation  of  exudates  and  transudates, 
and  in  nephritis. 

Urea. — Quantitative  Estimation;  Hypobro- 
mite  Method. — This  quantitative  test  is  based  upon 
the  principle  that  an  alkaline  solution  of  hypobro- 
mite  of  soda  will  decompose  urea  into  nitrogen,  and 
carbon  dioxide,  which  is  absorbed  in  the  excess  of 
alkali.  The  amount  of  urea  is  estimated  by  the 
volume  of  nitrogen  set  free.  Hiifner  has  shown 
that  one  cubic  centimetre  of  nitrogen  (at  0°  C.  and 
760  mm.  pressure)  represents  .00268  gramme  of 
urea.  A  convenient  method  (Rice)  of  preparing 
the  hypobromite  reagent  is  as  follows :  ( 1 )  A  solu- 
tion is  made  by  dissolving  100  grammes  of  NaOH 
in  250  c.c.  of  water;  (2)  a  solution  of  bromine 
one  part,  potassium  bromide  one  part,  and  water 
eight  parts.  These  solutions  are  mixed  in  equal 
amounts.  Special  forms  of  apparatus  have  been 
devised  for  collecting  the  nitrogen  and  measuring 
its  volume.  The  Heintz  modification  of  the  Doremus  apparatus  can  be 
highly  recommended  because  it  is  easy  to  operate  and  is  sufficiently  accurate 
for   clinical   purposes.      With   this   apparatus   the   test   is   conducted   as 


Fig.  119.— Heintz  modifi- 
cation of  Hiifner  apparatus  for 
urea  determination.  A,  bulb; 
B,  graduated  tube  to  collect 
and  measure  the  nitrogen;  C, 
tube  for  urine;  D,  stop-cock. 


EXAMINATION  OF  THE  URINE.  291 

follows:  The  large  tube  is  filled  with  hypobromite  reagent  and  the  small 
tube  with  urine  up  to  the  point  indicated  by  the  mark  1.  By  opening  the 
stop-cock,  one  cubic  centimetre  of  urine  is  allowed  to  flow  very  slowly  into 
the  large  tube.  The  reaction  occurs  immediately  and  nitrogen  gas  is  set 
free  and  collects  in  the  upper  part  of  the  tube  by  displacing  the  fluid.  The 
apparatus  is  then  set  aside  for  fifteen  minutes,  when  the  reading  is  taken. 
The  amount  of  urea  for  one  cubic  centimetre  of  urine  is  indicated  by  a 
graduated  scale  at  the  upper  level  of  the  fluid.  Albumin  should  always  be 
removed  before  making  this  test. 

The  Urease  Method  for  the  determination  of  urea  is  probably  the  most 
satisfactory.  The  method  depends  upon  the  principle  that  the  enzyme 
urease  is  able  at  ordinary  temperatures  to  transform  urea  into  ammonium 
carbonate,  quickly  and  completely.  The  urine  is  treated  with  urease.  Aerate 
the  ammonia  formed  into  fiftieth  normal  acid  and  titrate  the  excess 
acid  with  fiftieth  normal  alkali.  The  number  of  c.c.  of  fiftieth  normal  acid 
neutralized  is  multiplied  by  the  factor  0.056  to  measure  the  number  of 
grammes  of  urea — plus  ammonia-nitrogen  in  100  c.c.  of  urine.1 

On  an  ordinary  diet  the  daily  amount  of  urea  varies  between  20  and 
40  grammes,  on  a  rich  diet  it  may  reach  100  grammes,  while  on  a  restricted 
diet  it  is  sometimes  reduced  to  15  grammes.  As  a  rule  the  quantity  of 
urea  and  the  total  nitrogen  output  are  parallel,  so  that  for  clinical  purposes 
the  amount  of  urea  is  generally  determined  instead  of  the  total  nitrogen. 
Urea  may  show  a  reduction  with  a  rise  in  the  ammonia  elimination. 

Uric  Acid. — Folin's  Modification  of  Hopkin's  Test. — Three  hundred 
cubic  centimetres  of  urine  are  treated  with  75  c.c.  of  a  reagent  prepared  as 
follows:  500  grammes  of  ammonium  sulphate  and  5  grammes  of  uranium 
acetate  are  dissolved  in  650  c.c.  of  water,  to  which  are  added  60  c.c.  of  a 
10  per  cent,  acetic  acid  solution,  and  water  enough  to  bring  the  amount  up 
to  1  litre.  After  standing  for  about  five  minutes  the  urine  so  treated  is 
filtered  through  two  thicknesses  of  filter-paper.  Into  each  of  two  beakers 
125  c.c.  of  filtrate  are  poured,  treated  with  5  c.c.  of  concentrated  ammonia, 
and  set  aside  for  twenty-four  hours.  The  ammonium  urate  precipitate  is 
next  washed  with  a  small  quantity  of  a  10  per  cent,  solution  of  ammonium 
sulphate.  The  precipitate  of  ammonium  urate  collected  on  filter-paper  is 
washed  with  100  c.c.  of  water  into  a  beaker,  after  perforating  the  filter- 
paper.  The  solution  is  finally  treated  with  15  c.c.  of  concentrated  sulphuric 
in- id  and  then  immediately  titrated  with  a  1/20  normal  solution  of  potas- 
sium permanganate,  until  a  faint  red  color  tints  the  entire  solution.  This 
color  disappears  rapidly.  Each  cubic  centimetre  of  a  1/20  normal  per- 
manganate solution  represents  .00375  gramme  of  uric  acid. 

Uric  acid  is  an  oxidation  product  of  the  xanthin  bases.  Its  origin 
depends  upon  the  nucleins  derived  from  the  food  (exogenous  uric  acid)  and 
from  the  body  tissues  (endogenous  uric  acid).  The  normal  daily  amount 
of  uric  aeid  found  in  the  urine  varies  between  .2  and  1.25  grammes,  which 
represents  from  1  to  2  per  cent,  of  the  total  nitrogen  output.  Uric  acid  is 
increased   by  a  diet  rich  in  nuclear  proteids,  active   muscular  evn-ise.    in 

1  Sec  Fuke  (Journ.  Biol.  Chem.,  23-455,  1915), Van  Slyke  and  Cullen  (Journ.  Biol.  Chem.,  24,  117,  1916) 
-- 1  r  i « l  Hawk  (Practical  Physiological  Chemistry,  5th  edition)  foi  details  of  method. 


292  MEDICAL  DIAGNOSIS. 

fevers,  in  anaemia,  in  leukaemia,  in  pneumonia  during  the  stage  of  resolu- 
tion, in  cirrhosis  of  the  liver,  and  in  diabetes  mellitus.  In  gout  the  amount 
of  uric  acid  is  generally  decreased  between  the  acute  attacks,  and  rises  dur- 
ing and  immediately  after  the  paroxysm.  In  gout  an  increase  of  uric  acid 
is  found  in  the  blood  (uratsemia).  The  mere  existence  of  urataemia  does 
not  justify  the  conclusion  that  it  is  the  principal  or  primary  factor  of 
this  disease ;  on  the  contrary,  it  would  appear  that  an  increase  of  urates 
which  occurs/  in  a  number  of  conditions,  as  anaemia,  leukaemia,  and  during 
the  resolution  stage  of  pneumonia,  does  not  in  itself  favor  precipitation 
of  biurate  of  sodium.  It  has  been  suggested  that  an  excess  of  sodium  salts 
in  the  blood,  lymph,  and  especially  in  synovial  fluid,  determines  the  precipi- 
tation of  urates.  Solutions  of  uric  acid  have  been  shown  to  possess  only 
slightly  toxic  or  harmless  properties  when  injected  into  the  tissues  of  animals. 

The  quantity  of  urio  acid  in  the  urine  is  decreased  on  a  restricted  diet, 
especially  one  poor  in  substances  containing  nucleins,  after  the  adminis- 
tration of  large  doses  of  quinine,  in  nephritis,  and  in  certain  chronic  diseases. 
At  the  present  time  a  final  opinion  as  to  the  role  played  by  uric  acid  in  the 
so-called  uric  acid  diathesis  cannot  be  given. 

Xanthin  Bases. — Under  this  heading  is  included  a  group  of  substances 
found  in  the  urine  in  very  small  amounts  and  regarded  as  being  formed 
from  nucleins.  In  this  group  may  be  included  xanthin,  hypoxanthin, 
heteroxanthin,  paraxanthin,  guanin  and  adenin.  In  the  main  it  may  be 
said  that  the  amounts  of  uric  acid  and  the  xanthin  bases  fluctuate  in  a  paral- 
lel manner.  The  xanthin  bases  are  increased  in  the  urine  in  leukaemia,  after 
a  diet  rich  in  nucleins,  and  in  pneumonia.    Rarely,  calculi  consist  of  xanthin. 

Ammonia.  —  The  normal  daily  output  of  ammonia  is  about  0.7  gramme, 
which  represents  slightly  over  four  per  cent,  of  the  total  nitrogen  elimina- 
tion. It  exists  in  combination  with  some  of  the  urinary  acids.  Its  presence 
in  the  urine  is  accounted  for  by  a  small  amount  of  ammonia  which  is  not 
transformed  into  urea  in  the  liver.  Ammonia  is  increased  in  conditions 
associated  with  deficient  oxidation,  as  cardiac  dyspnoea,  in  certain  diseases 
of  the  parenchyma  of  the  liver,  such  asi  acute  yellow  atrophy  and  phos- 
phorus poisoning,  in  diabetes  mellitus,  and,  notably,  in  pernicious  vomit- 
ing of  pregnancy. 

Chlorides. —  Quantitative  Determination. — Ten  cubic  centimetres 
of  urine  are  diluted  with  90  c.c.  of  water,  to  which  are  then  added  a  few 
drops  of  a  strong  potassium  chromate  solution.  A  standard  silver  solution 
(1  c.c.  of  which  represents  .0035  gramme  of  chlorine,  or  .0058  gramme  of 
NaCl)  is  then  slowly  added  from  a  graduated  burette.  The  development  of  a 
permanent  orange  color  indicates  that  all  the  chlorine  has  been  precipitated. 

The  excretion  of  chlorides,  which  varies  from  10  to  15  grammes  per  day, 
depends  almost  exclusively  upon  the  quantity  of  chlorides  ingested.  A 
decreased  elimination  is  present  on  a  diet  poor  in  chlorides,  in  the  acute 
fevers  (probably  due  to  a  deficiency  of  chlorides  in  the  fever  diet),  before 
the  crisis  in  pneumonia,  in  acute  and  chronic  nephritis,  in  many  chronic 
diseases,  in  gastric  disorders  associated  with  vomiting,  in  diseases  attended 
with  diarrhoea,  and  during  the  formation  of  transudates  and  exudates. 
An  augmented  elimination  is  observed  after  a  diet  rich  in  chlorides,  after 


EXAMINATION  OF  THE  URINE.  293 

the  acute  fevers,  especially  during-  the  stage  of  resolution  of  pneumonia,  in 
diabetes  insipidus,  and  from  rapid  resorption  of  transudates  and  exudates. 

Phosphates. — Phosphoric  acid  of  the  urine  is  combined  with  sodium, 
potassium,  ammonium,  calcium,  and  magnesium.  The  daily  amount  of 
phosphoric  acid  excreted  by  the  kidneys  varies  between  two  and  three 
grammes.  A  diminished  excretion  has  been  noted  in  some  febrile  diseases, 
in  cases  of  arthritis,  between  the  paroxysms  of  gout,  in  pregnancy,  in  acute 
yellow  atrophy  of  the  liver,  in  nephritis,  in  Addison's  disease,  and  in  chronic 
lead  poisoning.  An  increased  elimination  has  been  noted  on  a  diet  rich 
in  meat,  during  the  attack  of  gout,  in  diabetes  mellitus,  in  neurasthenia, 
in  hysteria,  in  leukaemia,  and  after  active  muscular  exercise.  The,  existence 
of  a  phosphatic  deposit  in  the  urine. is  not  necessarily  a  sign  of  increased 
elimination,  and  is  frequently  due  to  alkalinity  of  the  urine.  A  quantita- 
tive estimation  of  phosphoric  acid  is  necessary  to  establish  an  increased 
output.  Neubauer  's  method  consists  in  titrating  the  urine  with  a  uranium 
nitrate  solution,  using  cochineal  as  an  indicator.  For  the  details  of  this 
method  special  wrorks  on  urinary  chemistry  should  be  consulted. 

Sulphates.  —  Sulphuric  acid  exists  in  the  urine  as  mineral,  preformed 
or  neutral  sulphates,  and  as  conjugate  or  ethereal  sulphates.  The  total 
daily  output  of  sulphuric  acid  varies  between  2  and  3  grammes,  nine-tenths 
of  which  is  eliminated  as  mineral  sulphates  and  the  remainder  as  ethereal 
sulphates.  Ethereal  sulphates  occur  in  combination  with  certain  aromatic 
bodies,  the  most  important  of  these  being  phenol,  indoxyl,  skatoxyl,  and 
cresol.  The  sulphate  elimination  is  controlled  principally  by  proteid  metab- 
olism, so  that  the  amount  is  increased  after  a  diet  rich  in  meat,  by  muscular 
exercise,  in  the  acute  febrile  diseases,  in  acute  inflammatory  diseases  of 
the  brain  and  spinal  cord,  and  by  certain  poisons  which  augment  proteid 
destruction.  The  output  of  sulphates  is  reduced  by  a  vegetable  diet  or 
one  poor  in  proteids.  during  the  period  of  convalescence  from  the  acute 
fevers,  and  in  many  chronic  diseases.  The  quantity  of  ethereal  sulphates 
depends  mainly  upon  putrefactive  chances  occurring  in  the  intestinal  tract, 
and  sometimes  in  other  parts  of  the  body.  The  normal  proportion  of 
ethereal  sulphate  to  neutral  sulphate  varies  considerably.  The  conjugate 
sulphates  are  diminished  by  starvation,  by  the  administration  of  calomel 
and  hydrochloric  acid,  and  are  increased  by  the  ingestion  of  alkalies  and 
carbolic  acid,  in  intestinal  diseases  associated  with  increased  putrefaction. 
as  in  constipation,  enteric  fever,  and  tuberculous  enteritis. 

Indican. — Obermayer's  Test. — The  reagent  for  this  method  is  made 
by  dissolving  two  parts  of  ferric  chloride  in  1000  parts  of  concentrated 
hydrochloric  acid.  A  small  amount  of  urine  is  treated  with  an  equal  part 
of  Obermayer'a  reagenl  and  the  mixture  shaken  with  2  or  3  cubic  centi- 
metres of  chloroform,  which  extracts  indican.  Tt  is  light  blue  or  colorless 
when  a  normal  amount  is  present,  while  an  increased  quantity  is  shown 
by  a  dark  bine  color. 

Jaffe's  Test  Modified  by  Stokvis. — Equal  volumes  of  hydrochloric 
acid  and  urine  are  mixed.  The  liquid  is  treated  with  a  droplet  of  a  con- 
centrated solution  of  sodium  or  calcium  hypochlorite  and  then  shaken  with 
a  few  e.e.  of  chloroform.     A  bine  color  is  imparled  to  the  chloroform  by  the 


294  MEDICAL  DIAGNOSIS. 

indigo.  An  approximate  estimate  of  the  amount  may  be  formed  by  the 
depth  of  this  color.  Iodine  in  the  urine  tints  the  chloroform  pink.  Bile 
pigment  should  always  be  removed  with  lead  subacetate  before  testing 
for  indican.  Indol  is  formed  in  the  intestines  as  a  result  of  putrefactive 
processes;  in  the  blood  it  is  oxidized  and  combines  with  sulphuric  acid, 
being  eliminated  as  sodium  or  potassium  indoxyl  sulphate  or  indican.  As 
putrefaction  is  essential  for  the  formation  of  indican,  only  small  traces  of 
this  substance  occur  in  the  urine  of  healthy  persons,  since  intestinal  decom- 
position is  slight  under  normal  conditions.  The  quantity  of  indican  is 
influenced  by  the  character  of  food,  being  smaller  upon  a  milk  than  on  a 
full  mixed  diet.  Jaffe  found  that  6.6  mg.  was  the  average  normal  amount 
for  1000  c.c.  of  urine. 

Pathological  indicanuria  occurs  in  carcinoma  of  the  stomach,  in  cer- 
tain forms  of  gastritis,  and  in  conditions  associated  with  inhibited  intes- 
tinal peristalsis,  as  constipation,  intestinal  obstruction,  and  peritonitis. 
The  amount  of  indican  is  augmented  in  putrid  bronchitis,  in  empyema,  and 
in  gangrene  and  abscess  of  the  lungs. 

Urinary  Pigments. —  The  color  of  normal  urine  depends  chiefly  upon 
urochrome.  The  following  pigments  are  responsible  for  the  color  of  many 
abnormal  urines :  pathological  urobilin,  uroerythrin,  haemoglobin,  methaemo- 
globin,  urohsematin,  uroroseinogen,  biliary  pigment,  and  melanin.  After 
the  ingestion  of  senna,  santonin,  iodine,  phenol,  and  creosote  abnormal 
pigmentation  of  the  urine  often  occurs. 

Biliary  Pigments.- — Rosenbach's  Modification  of  Gmelin's  Method. 
— The  urine  is  filtered  through  thick  filter-paper.  A  drop  of  concentrated 
nitric  acid  is  then  placed  upon  the  urine-soaked  filter-paper.  A  play  of 
colors,  consisting  of  red,  yellow,  green,  blue  and  violet,  in  which  the  green 
predominates,  will  develop  in  the  presence  of  biliary  pigment. 

Smith's  Test. — A  mall  amount  of  tincture  of  iodine  diluted  with  10 
parts  of  alcohol  is  added  to  5  or  10  c.c.  of  urine,  so  that  the  iodine  solution 
forms  a  layer  above  the  urine.  An  emerald  color  forms  at  the  zone  of 
contact  of  two  fluids  when  bilirubin  isi  present.  Biliary  acids  are  associated 
with  bilirubin  so  that  their  clinical  significance  is  practically  the  same. 
The  tests  for  biliary  acids  are  attended  with  considerable  difficulty. 

The  biliary  pigments' are  bilirubin,  biiiverdin,  bilifuscin,  and  biliprasin. 
Bilirubin  is  found  in  freshly  voided  urine  only,  while  the  other  pigments 
may  appear  after  the  urine  has  stood  for  a  time.  Biliary  pigment  occurs 
in  the  urine  in  both  toxremic  and  obstructive  jaundice. 

Phenol. — Salkowski's  Test. — About  10  c.c.  of  urine  is  treated  with 
a  few  c.c.  of  nitric  acid  and  boiled.  On  cooling,  bromine  water  is  added. 
An  increased  amount  of  phenol  is:  shown  by  the  development  of  a  decided 
cloudiness  or  precipitate. 

The  amount  of  phenol  eliminated  is  very  small  (0.3  gramme  daily 
under  normal  conditions).  This  substance  is  increased  whenever  putrefac- 
tive processes  occur  in  the  body,  as  in  gangrene,  putrid  bronchitis,  em- 
pyema, and,  rarely,  from  intestinal  decomposition.  It  has  also  been  demon- 
strated in  tuberculosis,  meningitis,  peritonitis,  erysipelas,  scarlet  fever, 
and  from  poisoning  with  phenol  or  some  of  its  derivatives,  such  as  salicylic 


EXAMINATION  OF  THE  URINE.  295 

acid,  pyrocatechin  and  hydroquinone.  The  urine  containing-  phenol  may 
become  dark  brown  or  black  on  standing. 

Pathological  Urobilin.  —  Braunstein's  Test. — About  20  c.c.  of  urine 
are  mixed  with  5  c.c.  of  a  reagent  which  consists  of  100  parts  of  a  con- 
centrated solution  of  cupric  sulphate,  6  parts  of  hydrochloric  acid,  and  3 
parts  of  ferric  chloride.  A  small  amount  of  chloroform  is  added  to  the 
mixture.    On  shaking,  the  chloroform  becomes  rose  colored. 

This  pigment  is  closely  related  to  urochrome  and  can  be  differentiated 
from  the  latter  by  the  spectroscope.  Urobilin  and  its  chromogen  are  solu- 
ble in  chloroform  and  precipitated  with  ammonium  sulphate.  Pathological 
urobilin  is  sometimes  encountered  in  the  urine  in  febrile  diseases,  cirrhosis 
of  the  liver,  pernicious  anaemia,  cancer,  cerebral  hemorrhage,  scurvy,  Addi- 
son's disease,  haemophilia,  and  syphilis. 

Melanin  and  Melanogen. — These  substances  are  occasionally  found  in 
the  urine  of  persons  suffering  from  melanotic  tumors,  chronic  malaria,  and 
certain  wasting  diseases.  The  urine  containing  melanin  and  melanogen 
may  have  a  normal  yellow  color  when  voided,  but  becomes  darker  when 
exposed  to  the  air. 

Albumins. — The  proteids  found  in  the  urine  are  serum  albumin,  serum 
globulin,  nucleo-albumin,  albumose,  Bence-Jones's  albumin,  haemoglobin, 
fibrin  and  histon.  The  most  important  of  these  from  a  clinical  standpoint 
is  serum  albumin. 

Serum  Albumin. —  The  most  useful  tests  for  the  detection  of  albumin 
are  the  boiling  and  acidulation  tests  and  Heller's  test,  because  they  afford 
uniformly  satisfactory  results,  are  simple  and  easily  applied.  It  is  claimed 
that  these  tests  are  less  sensitive  than  many  others,  such  as  Speigler's  and 
Tanret's.  Before  testing  for  albumin  the  urine  should  be  clear,  and,  if 
cloudy,  must  be  filtered  through  several  layers  of  filter-paper.  Bacteria 
cannot  be  completely  removed  by  filtration  through  ordinary  filter-paper. 
It  is  desirable  to  have  a  fresh  specimen  for  testing.  In  certain  cases  several 
samples  should  be  secured,  i.e.,  the  first  urine  passed  in  the  morning  on 
arising,  and  that  voided  late  in  the  afternoon.  Albumin  reactions  are 
sometimes  less  distinct  in  concentrated  specimens  than  in  those  of  low 
specific  gravity,  and  it  is,  therefore,  advisable  to)  dilute  an  inspissated  urine 
before  applying  albumin  tests. 

Boii.ix<;  and  Acidulation  Test. — Clear  urine  is  boiled  in  a  test-tube. 
When  a  precipitate  forms  this  is  generally  due  to  either  phosphates  or 
albumin  (serum  albumin  in  conjunction  with  serum  globulin).  The  tur- 
bidity caused  by  phosphates  clears  on  the  addition  of  a  few  drops  of  color- 
less nitric  acid,  while  the  cloud  due  to  albumin  remains  or  even  is  intensi- 
fied after  acidulation.  A  precipitate  of  carbonates,  developing  on  heating, 
will  disappear  upon  the  addition  of  nitric  acid  with  the  liberation  of  gas 
(CO.).  If  on  boiling  the  urine  remains  clear  but  subsequently  on  cooling 
a  cloud  develops,  this  is  due  to  albumose.  This  turbidity  will  again  dis- 
appear  on  heating.  Certain  resinous  bodies,  as  copaiba,  benzoin,  cubebs, 
and  turpentine,  also  produce  a  precipitate  on  heating.  This  cloud  can 
be  distinguished  from  that  produced  by  albumin  by  the  fact  that  alcohol 
dissolves  the  turbidity  produced  by  these  substances.     When  employing 


296  MEDICAL  DIAGNOSIS. 

acetic  acid,  it  is  best  to  add  a  few  drops  before  boiling,  care  being  taken 
to  avoid  an  excess,  since  albumin  may  not  precipitate  on  boiling.  If  a 
cloud  forms  after  the  urine  is  treated  with,  acetic  acid,  this  is  caused 
by  nucleo-albumin  and  should  be  removed  by  filtration  before  testing  for 
serum  albumin.  The  most  accurate  results  are  obtained  with  this  method 
when  a  dilute  acetic  acid  solution  is  employed  (25  per  cent.). 

Heller's  Test.- — Colorless  nitric  acid  is  allowed  to  flow  slowly  from 
a  pipette  into  a  test-tube  or  a  conical  glass  vessel  containing  a  small  quan- 
tity of  urine,  so  that  the  urine  forms  a  distinct  layer  above  the  acid.  In 
order  to  prevent  mixing  the  acid  and  urine,  the  test-tube  or  conical  vessel 
should  be  inclined  while  adding  the  nitric  acid.  When  serum  albumin  is 
present  a  white  disk  appears  at  the  zone  of  contact  between  the  urine  and 
acid.  When  a  small  amount  of  albumin  exists  the  precipitate  does  not 
form  immediately  but  in  the  course  of  several  minutes.  An  approximate 
quantitative  estimate  of  albumin  can  be  formed  from  the  thickness  of  the 
coagulated  layer.  A  pale  red  or  reddish-violet  disk,  at  or  above  the  plane 
of  contact,  is  noted  in  many  normal  and  abnormal  urines.  A  white  pre- 
cipitate is  also  caused  by  serum  globulin  and  albumose.  The  latter  dis- 
appears on  heating  and  reappears  on  cooling.  Nucleo-albumin  in  large 
amounts  may  give  a  positive  reaction,  but  this  is  so  uncommon  that  it 
can  be  disregarded  for  practical  purposes.  Certain  resinous  bodies,  indi- 
cated in  the  discussion  of  the  boiling  and  acidulation  test,  produce  a  white 
cloud  which  disappears  when  treated  with  alcohol. 

Acetic  Acid  and  Potassium  Ferrocyanide  Test.  —  A  few  drops 
of  10  per  cent,  solution  of  potassium  ferrocyanide  or  platinocyanide  are 
added  to  a  small  amount  of  urine  previously  acidified  with  acetic  acid.  A 
precipitate  indicates  albumin  or  albuminose.  If,  on  heating,  the  turbidity 
disappears  completely,  the  presence  of  the  latter  substance  is  indicated,  or, 
if  the  cloud  partly  clears  on  warming,  the  presence  of  both  substances'  may 
be  inferred.  When  a  precipitate,  due  to  nucleo-albumin,  forms  on  addi- 
tion of  acetic  acid,  the  urine  should  be  filtered  and  the  test  repeated. 

Tanret's  Test. — The  reagent  is  prepared  as  follows:  Dissolve  1.35 
grammes  of  mercuric  chloride  in  25  c.c.  of  water,  add  to  this  solution  3.32 
grammes  of  potassium  iodide  dissolved  in  25  c.c.  of  water,  then  make  the 
total  solution  up  to  60  e.d.  with  water  and  add  20  c.c.  of  glacial  acetic  acid 
to  the  combined  solutions. 

Technic— To  5  c.c.  of  albumin  solution  in  a  test-tube  add  Tanret's 
reagent,  drop  by  drop,  until  a  turbidity  or  precipitate  forms.  This  is  an 
exceedingly  delicate  test.  Sometimes  the  albumin  solution  is  stratified  upon 
the  reagent  as  in  Heller's  or  Roberts'  ring  tests.  It  is  claimed  by  Repiton 
that  the  presence  of  urates  lowers  the  delicacy  of  the  test.  Tanret  claims 
that  the  removal  of  urates  is  not  necessary  inasmuch  as  the  urate  precipi- 
tate will  disappear  on  warming  and  the  albumin  precipitate  will  not.  He 
says,  however,  that  mucin  interferes  with  the  delicacy  of  his  test  and  should 
be  removed  by  acidification  with  acetic  acid  and  filtration  before  testing 
for  albumin. 

Spiegler's  Test. — The  test  solution  as  modified  by  Jolles  consists  of 
mercuric  chloride  10  grammes,  succinic  acid  20  grammes,  sodium  chloride 


EXAMINATION  OF  THE  URINE. 


297 


20  grammes,  and  distilled  water  500  c.c.  The  reagent  is  added  slowly  by 
means  of  a  pipette  to  a  small  amount  of  urine  contained  in  a  test-tube,  so 
that  the  urine  forms  a  layer  above  the  test  solution.  A  white  cloud  at  the 
junction  of  the  fluids  indicates  albumin,  nucleo-albumin  or  albumose.  "When 
the  urine  contains  iodine,  a  precipitate  of  mercuric  iodide  forms,  which  is 
soluble  in  alcohol.     This  test  is  very  sensitive. 

Many  other  methods  for  the  detection  of  albumin  are  recommended  by 
different  authorities,  as  tests  with  picric  acid,  metaphosphorie  acid,  phos- 
photungstic  acid,  and  trichloracetic  acid. 

Quantitative  Determination  of  Albumin.    Esbach  s  Method. — The 
test  solution  is  prepared  by  dissolving  10  grammes  of  picric  acid  and  20 
grammes  of  citric  acid  in  1000  c.c.  of  distilled  water.     A  special  graduated 
test-tube  devised  by  Esbach  and  known  as  an  albuminometer 
is  required  for  this  method.     The  urine  should  have  an  acid  f        7 

reaction.     It  is  poured  into  the  albuminometer  to  the  mark  \       j 

"U";  the  reagent  is  then  added  until  the  fluid  reaches  to  the 
mark  "R.'J  The  fluids  are  then  mixed  and  the  test-tube  set 
aside  for  twenty-four  hours,  when  the  reading  is  taken.  The 
height  of  the  column  of  coagulated  albumin,  as  measured  by 
the  scale  on  the  tube,  represents  the  amount  pro  mille. 
Esbach 's  reagent  precipitates  serum  albumin,  serum  globulin, 
albumose,  uric  acid,  and  creatinin.  When  the  specific  gravity 
exceeds  1.008,  or  when  a  large  amount  of  albumin  exists,  the 
urine  should  be  diluted  with  one  or  several  volumes  of  water 
before  applying  the  test.  The  reading  is  multiplied  by  the 
number  of  dilutions.  Esbach 's  method,  although  not  so  accu- 
rate as  the  gravimetric  determination,  is  quite  satisfactory 
for  general  clinical  purposes. 

Boiling  Test. — An  approximate  estimate  of  the  quantity 
of  albumin  can  be  formed  by  boiling  acidified  urine  in  a  test- 
tube  and  allowing  the  precipitate  to  settle  for  twenty-four 
hours.  The  error  with  this  method  may  be  considerable, 
because  albumin  sometimes  separates  in  large  and  at  other 
tiim^  in  small  flakes. 

Gravimetric  Method. — One  hundred  cubic  centimetres 
of  urine  are  sufficiently  acidulated  with  acetic  acid  to  insure 
separation  of  all  the  albumin.  It  is  then  boiled  and  passed  through  a  filter 
of  known  weight.  The  precipitate  collected  on  the  filter  is  washed  with  hot 
water  until  the  washings  cease  to  give  a  reaction  for  chlorides.  The  pre- 
cipitate is  next  washed  successively  with  alcohol  and  ether  to  remove  Eat. 
The  filter  containing  the  precipitate  is  now  dried  at  a  temperature  of  120 
to  130  and  then  carefully  weighed.  The  weighl  <>f  the  albumin  is  obtained 
by  subtracting  the  weight  of  the  filter-paper  from  the  combined  weight  of 
the  filter-paper  and  dried  precipitate. 

Albuminuria.- — The  term  albuminuria  implies  the  presence  in  the  urine 
of  coagulable  albumin,  and  refers  particularly  to  serum  albumin,  (hie  or 
more  albuminous  bodies  are  almost  invariably  associated  with  serum  albu- 
min. Albuminuria  is  symptomatic  of  a  large  uumber  of  morbid  states, 
from  minor  disturbances  in  health  1o  malignant  diseases. 


— U 


w 


Fig.  120.— 
Esbacli".-  albu- 
minometer. — 
Emerson. 


298  MEDICAL  DIAGNOSIS. 

1.  Renal  Albuminuria. — When  albumin  is  eliminated  by  the  kidneys 
the  condition  is  termed  renal  albuminuria. 

fa)  So-called  physiological  albuminuria  is  occasionally  noted  in  healthy 
individuals  after  violent  exercise  or  severe  nervous  stress.  Whether  albu- 
minuria is  ever  physiological  is  still  a  mooted  question.  Albuminuria  often 
occurs  in  pregnancy,  especially  in  the  later  stages.  The  so-called  albu- 
minuria of  adolescents  is  probably  pathological. 

(b)  Albuminuria  of  Organic  Kidney  Disease. — In  this  variety  the 
presence  of  albumin  in  the  urine  depends  directly  on  structural  changes 
in  the  renal  tissues,  and  in  nephritis,  and  amyloid,  tuberculous,  malignant 
and  cystic  disease  of  the  kidney.  In  acute  and  chronic  parenchymatous 
nephritis  the  amount  is  generally  large,  while  in  amyloid  disease  it  is  moder- 
ate or  small,  and  in  contracted  kidney  it  is  small.  The  mere  presence  of 
albumin  in  the  urine  never  warrants  a  diagnosis  of  organic  renal  disease; 
on  the  other  hand,  mere  traces  occur  in  granular  kidney,  and,  indeed,  albu- 
min may  be  absent  for  a  time  in  this  disease.  Large  quantities  of  albumin 
usually  justify  a  diagnosis  of  organic  kidney  disease. 

(c)  Febrile  Albuminuria. — A  discharge  of  albumin  of  slight  or  moder- 
ate degree  in  fevers  and  inflammatory  diseases  is  suggestive  of  a  simple 
parenchymatous  degeneration  of  the  kidney  and  of  vascular  derangements, 
incident  to  the  febrile  or  inflammatory  process,  while  a  high  grade  of  albu- 
minuria, noted  in  a  limited  number  of  these  cases,  points  to  marked  renal 
degeneration,  often  associated  with  decided  congestion.  The  difference 
between  albuminuria  of  febrile  and  inflammatory  disorders  and  that  of 
acute  Bright 's  disease  is  essentially  one  of  degree,  so  that  a  sharp  distinc- 
tion cannot  be  made  between  these  forms.  Albuminuria  is  symptomatic 
of  many  of  the  infectious  diseases,  especially  enteric  fever,  typhus  fever, 
pneumonia,  cerebrospinal  fever,  yellow  fever,  plague,  cholera,  malignant 
endocarditis,  diphtheria,  erysipelas,  and  variola. 

(d)  Toxic  Albuminuria. — Under  this  heading  is  included  the  albu- 
minuria produced  by  drugs,  such  as  salicylic  acid,  potassium  iodide,  salol, 
urotropine,  phenol,  alcohol,  ether,  chloroform,  lead,  mercury,  phosphorus, 
and  a  number  of  other  toxic  substances. 

(e)  Albuminuria  occurring  in  blood  disorders  is  seen  in  severe  second- 
ary anaemias,  pernicious  anaemia,  chlorosis,  and  leukaemia. 

(f )  Alimentary  Albuminuria. — The  ingestion  of  very  large  amounts  of 
albumin,  such  as  raw  eggs,  may  excite  albuminuria,  but  a  moderate  quan- 
tity of  albuminous  food  will  never  produce  albuminuria  in  a  healthy  person. 
An  antecedent  chronic  albuminuria  may  be  intensified  by  a  moderate  con- 
sumption of  albumin. 

(g)  Albuminuria  dependent  upon  circulatory  disturbances  of  the  kid- 
neys is  seen  in  cardiac  disease,  especially  during  the  stage  of  ruptured 
compensation,  in  pulmonary  disease  with  venous  stasis,  from  pressure  on 
the  renal  veins  by  a  tumor,  cyst  or  peritoneal  effusion,  and  by  a  thrombus 
in  these  vessels.  In  floating  kidney  albuminuria  sometimes  depends  on 
kinking  of  the  renal  veins  so  that  it  may  be  present  only  while  the  indi- 
vidual is  in  the  erect  posture,  disappearing  when  in  the  recumbent  position 
(orthostatic  albuminuria) . 


EXAMINATION  OF  THE  URINE.  299 

(h)  Albuminuria  in  nervous  diseases  is  common  when  organic  lesions 
of  the  nervous  system  exist,  such  as  apoplexy,  brain  tumor,  and  spinal 
sclerosis,  but  it  is  infrequent  in  functional  disorders,  such  as  neurasthenia 
and  migraine. 

(i)  Albuminuria  caused  by  obstruction  in  the  urinary  passages  occurs 
in  nephrolithiasis,  when  the  stone  blocks  up  the  ureter  for  a  time,  and  also 
when  the  ureter  is  compressed  by  a  tumor  or  is  twisted.  The  urine  which 
has  been  impeded  in  its  passage  shows  albumin  in  many  instances. 

2.  Accidental  Albuminuria. — When  the  urine  contains  albumin 
derived  from  the  renal  passages  or  genital  organs  it  is  designated  accidental 
or  extrarenal  albuminuria.  The  presence  of  pus,  blood,  leucorrhceal  dis- 
charge, and  chyle  in  the  urine,  as  a  rule,  causes  a  slight,  and  rarely,  a  moder- 
ate albumin  reaction.  This  type  occurs  in  pyelitis,  ureteritis,  cystitis, 
prostatitis,  vesiculitis,  epididymitis,  urethritis,  vulvovaginitis,  and  during 
menstruation.  A  vaginal  discharge  is  often  washed  into  the  urine.  The 
diagnosis  of  accidental  albuminuria  is  generally  unattended  with  difficulty, 
provided  the  results  of  microscopic  examination  and  the  clinical  investi- 
gation are  carefully  considered.  In  general  terms  it  may  be  said  that  the 
intensity  of  the  albumin  reaction  is  directly  proportionate  to  the  amount 
of  cellular  deposit.  The  differentiation  between  renal  and  extrarenal  albu- 
minuria rests  on  the  data  obtained  by  a  careful  urinalysis  with  other  clinical 
findings.  Both  conditions  often  coexist.  The  presence  of  tube-casts  and 
many  pus-cells  with  an  albumin  reaction  greater  than  the  number  of  leuco- 
cytes would  indicate,  argues  in  favor  of  a  coexistent  renal  and  accidental 
albuminuria. 

Serum  Globulin. — Kauder's  Test. — The  urine  is  treated  with  a  suffi- 
cient quantity  of  ammonia  to  separate  the  phosphates,  which  are  removed 
by  filtration.  An  equal  bulk  of  a  saturated  solution  of  ammonium  sulphate 
and  filtrate  are  mixed.    A  precipitate  represents  serum  globulin. 

Serum  globulin  and  serum  albumin  are  almost  invariably  associated, 
so  that  their  clinical  significance  is  similar.  As  a  rule  serum  albumin  is 
found  in  excess  of  serum  globulin,  although  exceptions  to  this  rule  are 
recorded  in  amyloid  disease,  diabetes,  and  severe  nephritis. 

Nucleo=albumin. — This  body  is  precipitated  by  strong  acetic  acid.  Con- 
centrated urines  should  always  be  diluted  with  two  or  three  volumes  of 
water  before  applying  this  test.  Urine  containing  much  serum  albumin  and 
serum  globulin  should  be  boiled  and  filtered  in  order  to  remove  these 
substances  before  testing  for  nucleo-albumin. 

Ott's  Method. — Add  to  the  urine  an  equal  volume  of  saturated  solu- 
tion of  sodium  chloride,  and  treat  the  mixture  with  Almen's  tannin  solution. 
The  presence  of  nucleo-albumin  is  .shown  by  flu-  formation  of  an  abundant 
precipitate.  Almen's  solution  consists  of  5  grammes  of  tannic  acid,  10  c.c. 
of  a  25  per  cent,  solution  of  acetic  acid,  and  240  c.<-.  of  50  per  cent,  ethyl 
alcohol.    Nucleo-albumin  can  be  removed  from  the  urine  with  neutral  lend 

JiCctrlte. 

With  certain  delicate  tests  aucleo-albumin  can  be  demonstrated  in 
many  normal  and  abnormal  specimens,  so  that  its  presence  in  small  amount 
may  be  regarded  as  physiological.     When  nucleo-albumin  can  lie  detected 


300  MEDICAL  DIAGNOSIS. 

by  tests  generally  employed  in  routine  clinical  work,  it  is  probably  patho- 
logical. Nucleo-albuminuria  occurs  in  inflammatory  diseases,  especially  of 
a  catarrhal  nature,  of  the  urinary  tract,  as  cystitis  and  pyelitis.  In  febrile 
diseases  associated  with  albuminuria,  in  leukaemia,  in  jaundice,  and  in  acute 
nephritis,  nucleo-albuminuria  is  not  uncommon.  In  the  last  named  disease 
nucleo-albuminuria  sometimes  precedes  and  follows  serum  albuminuria. 

Albumose. — To  the  urine  strongly  acidulated  with  acetic  acid,  is  added 
an  equal  amount  of  a  saturated  solution  of  sodium  chloride.  The  presence 
of  a  precipitate,  which  disappears  on  boiling  and  returns  on  cooling  the 
urine,  consists  of  albumose.  When  serum  albumin  coexists  with  albumose, 
this  must  be  removed  by  boiling  and  filtering  before  applying  the  test. 

Albumosuria  is  referred  to  by  some  writers  as  peptonuria,  a  term  which 
Kiihne  restricts  to  the  presence  of  true  peptone.  According  to  Kiihne, 
peptonuria  has  been  found  in  pneumonia,  phthisis,  and  gastric  ulcer.  The 
chief  clinical  significance  of  albumose  in  the  urine  relates  to  morbid  lesions, 
characterized  by  a  destruction  of  leucocytes,  with  the  absorption  of  the 
disintegrated  products.  In  many  diseases  showing  these  pathological 
features,  especially  in  purulent  collections,  the  occurrence  of  albumosuria 
may  be  a  useful  sign  in  diagnosis.  In  this  connection  it  must  be  pointed 
out  that,  since  the  group  of  conditions  in  which  it  occurs  is  a  vast  one,  its 
significance  is  of  less  value  in  diagnosis  than  any  other  urinary  findings. 
Albumosuria  has  been  noted  in  pneumonia  during  the  period  of  resolution, 
in  suppurative  meningitis,  in  liver  abscess,  in  septicaemia,  in  leukaemia,  in 
endocarditis,  in  myxcedema,  in  diphtheria,  in  measles,  in  rheumatic  fever, 
in  scarlet  fever,  in  acute  yellow  atrophy  of  the  liver,  in  scurvy,  in  dermatitis, 
and  in  intestinal  diseases  characterized  by  ulceration,  as  enteric  fever,  tuber- 
culosis, and  carcinoma.  Albumosuria  may  be  associated  with,  or  occur 
independently  of,  serum  albuminuria. 

Bence=Jones's  Albumose. — The  recognition  of  this  proteid  depends  upon 
the  fact  that  its  precipitation  occurs  at  a  temperature  of  52°  to  60°  C. 
Upon  boiling,  the  cloud  entirely  or  partially  disappears,  to  return  again  on 
cooling.  With  Heller 's  nitric  acid  test  Bence- Jones 's  albumin  gives  a  reac- 
tion like  that  of  serum  albumin. 

This  proteid,  first  described  by  Bence-Jones,  occurs  with  considerable 
frequency  in  myelomatous  growths  in  the  bones.  It  is  generally  designated 
as  albumose,  but  probably  incorrectly.  The  researches  of  Simon  and  Mag- 
nus Levy  indicate  that  it  is  a  true  albumin. 

Haemoglobin. — The  spectroscopic  examination,  as  a  rule,  shows  absorp- 
tion bands  of  methamioglobin,  sometimes  of  oxyhemoglobin. 

Donogany's  Test.- — If,  on  the  addition  of  1  c.c.  of  ammonium  sulphide 
solution  and  an  equal  quantity  of  pyridine  to  10  c.c.  of  urine,  an  orange 
color  develops,  the  presence  of  blood  may  be  inferred.  When  the  result  is 
doubtful,  a  spectroscopic  examination  should  be  made  of  the  mixture. 

The  physiological  destruction  of  red  corpuscles  is  not  followed  by 
hemoglobinuria,  because  the  coloring  matter  set  free  from  the  disintegrated 
erythrocytes  is  converted  wholly,  or  in  part,  in  the  liver  into  bile,  and,  per- 
haps, a  fraction  of  the  amount  is  redeposited  in  the  tissues  and  stored 
there  for  the  future  demands  of  the  system.     The  explanation  generally 


EXAMINATION  OF  THE  URINE.  301 

offered  to  elucidate  hemoglobinuria  is  based  upon  an  erythrocytolysis  so 
excessive  that  a  part  of  the  haemoglobin  liberated  into  the  plasma  (haemo- 
globimemia)  is  secreted  by  the  kidneys.  Hemoglobinuria  occurs  in  some 
cases  of  malarial  fever  (black  water  fever).  It  has  been  observed  in  yellow 
fever,  variola,  icterus  gravis,  scarlet  fever,  enteric  fever,  syphilis,  Raynaud's 
disease,  and  from  the  toxic  action  of  phenol,  potassium  chlorate,  snake 
venom,  hydrogen  sulphide,  carbon  monoxide,  and  after  exposure  to  the 
cold.  The  etiological  factor  responsible  for  paroxysmal  hemoglobinuria 
has  not  been  definitely  determined.  Some  writers  claim  that  exposure  to 
cold  is  the  exciting  cause,  while  others  hold  that  it  is  of  nervous  origin. 
Hematuria  is  much  more  common  than  hemoglobinuria. 

Fibrin. — -The  suspected  fibrin  clots  are  .separated  from  the  urine  by 
filtration,  then  thoroughly  washed  with  water  and  dissolved  by  boiling  in 
a  5  per  cent,  solution  of  hydrochloric  acid.  The  solution  thus  secured 
gives  the  test  for  serum  albumin  when  the  coagnlum  consists  of  fibrin. 

Fibrinuria  has  been  noted  in  hematuria,  chyluria,  and  in  pseudomem- 
branous inflammation  of  the  urinary  tract. 

An  acetosoluble  albumin  referred  to  by  Simon  as  Patein's  albumin  has 
been  reported  in  cystic  kidney  and  nephritis. 

Glucose. — Fresh  urine  is  desirable  for  quantitative  examinations  for 
sugar.  "When  albumin  is  present,  this  should  be  removed  from  the  urine 
before  testing  for  glucose. 

Fehling's  Test. — Two  solutions  are  required,  an  alkaline  and  a  copper 
solution,  which  should  be  mixed  just  before  applying  the  test.  Fehling's 
reagent  deteriorates  in  a  few  days*  to  such  an  extent  that  it  is  unsuited 
for  testing;  therefore,  it  is  necessary  to  keep  the  alkaline  and  copper  solu- 
tions in  separate  bottles  supplied  with  well-fitting  rubber  corks.  The  alka- 
line solution  consists  of  potassium  and  sodium  tartrate  173  grammes, 
potassium  hydrate  60  grammes,  and  500  c.c.  of  distilled  water.  The  copper 
solution  consists  of  eupric  sulphate  34.6-4  grammes,  dissolved  in  500  c.c.  of 
distilled  water.  Equal  volumes  of  these  solutions  are  poured  into  a  test- 
tube  and  shaken ;  the  mixture  is  then  diluted  with  four  parts  of  water  and 
boiled.  After  removing  the  test-tube  from  the  flame  the  urine  is  added  in 
small  amounts,  and  after  each  addition  the  mixture  heated  but  not  boiled. 
When  sugar  is  present  a  yellow  or  red  precipitate  of  eupric  suboxide  sepa- 
rates. A  change  of  the  blue  color  of  Fehling's  solution  to  green,  with  a 
slight  turbidity  of  the  liquid  after  the  addition  of  the  urine,  is  very  often 
seen,  and  may  not  be  caused  by  glucose.  Nearly  every  reducing  substance 
except  sugar  requires  boiling  to  produce  precipitation  of  eupric  suboxide. 

BENEDICTS  TEST— FORMULA 

Copper  sulphate    (pure  crystallized) 17.3  gm. 

Bodium  or  potassium  citrate 173.0  gm. 

Sodium  carbonate   (crystallized) 200.0  <jm. 

or  the  anhydrous  salt 100.0  gm. 

Distilled  water  to  make 1000.0  c.c. 

The  citrate  and  carbonate  are  dissolved  together  with  the  aid  of  heat 
in  about  700  c.c.  of  water.  The  mixture  is  then  poured,  through  a  lilter  if 
necessary,  into  a  larger  beaker  or  casserole.    The  copper  sulphate  dissolved 


302  MEDICAL  DIAGNOSIS. 

separately  in  about  100  e.e.  of  water  is  poured  slowly  into  the  first  solution, 
with  constant  stirring.  The  mixture  is  cooled  and  diluted  to  one  litre.  This 
test  solution  keeps  indefinitely. 

Technic. — For  the  detection  of  glucose  in  the  urine  about  5  c.c.  of  the 
reagent  are  placed  in  a  test-tube  and  8  to  10  drops  of  the  urine  to  be 
examined  are  added.  The  mixture  is  vigorously  boiled  for  one  or  two 
minutes,  and  allowed  to  cool  spontaneously.  In  the  presence  of  glucose  the 
entire  body  of  the  solution  will  be  filled  with  a  precipitate,  which  may  be 
red,  yellow,  or  greenish  in  tinge.  If  the  quantity  of  glucose  be  under  0.3 
per  cent,  the  precipitate  forms  only  on  cooling.  If  no  sugar  be  present, 
the  solution  either  remains  perfectly  clear,  or  shows  a  faint  turbidity  that 
is  blue  in  color,  and  consists  of  precipitated  urates.  In  the  use  of  the 
reagent  the  addition  of  a  small  quantity  of  urine — 8  to  10  drops — to  5  c.c. 
is  important,  not  because  larger  amounts  of  normal  urine  would  cause  reduc- 
tion of  the  reagent,  but  because  more  delicate  results  are  obtained  by  this 
procedure.  Vigorous'  boiling  of  the  solution  after  addition  of  the  urine, 
and  allowing  the  mixture  to  cool  spontaneously  are  also  important.  If 
sugar  is  present  the  solution,  either  before  or  after  cooling,  will  be  filled 
from  top  to  bottom  with  a  precipitate,  so  that  the  mixture  becomes  opaque. 
(Joslin.) 

Phenylhydrazine  Test. — About  .5  gramme  of  phenylhydrazine  hydro- 
chloride and  1  gramme  of  sodium  acetate  are  added  to  about  8  c.c.  of  urine 
contained  in  a  test-tube.  If  the  salts  do  not  dissolve  on  warming  the  urine, 
water  is  added  to  effect  solution.  The  tube  is  now  placed  in  boiling  water 
for  20  or  30  minutes,  then  removed,  and  rapidly  cooled  by  placing  the  test- 
tube  in  cold  water.  The  formation  of  a  bright  yellow  precipitate  indicates 
the  pi  esence  of  sugar.  Mere  traces  of  glucose  cause  a  small  amount  of 
precipitate  which  should  be  examined  microscopically  for  phenylglucosa- 
zone  crystals.  These  consist  of  yellow  needles  arranged  singly  or  in  clus- 
ters. Their  melting  point  is  205°  C.  In  experienced  hands  this  test  is 
generally  considered  the  most  sensitive. 

Nylander's  Modification  of  Boettger's  Test. — Almen's  reagent, 
required  for  this  method,  consists  of  4  grammes  of  potassium  and  sodium 
tartrate,  2  grammes  of  bismuth  subnitrate,  and  10  grammes  of  sodium 
hydrate  dissolved  in  90  c.c.  of  water.  This  solution  is  then  boiled  and,  after 
cooling,  is  filtered.  A  small  quantity  of  Almen's  reagent  isi  added  to  the 
urine,  approximately  in  the  proportion  of  1  to  11,  and  the  resultant  mix- 
ture is  boiled.  In  the  presence  of  sugar  a  dark  gray  or  black  precipitate  of 
metallic  bismuth  separates.  A  positive  reaction  may  be  given  by  albumin, 
melanin,  melanogen.  and  other  reducing  substances  found  in  the  urine 
after  the  ingestion  of  salol,  benzol,  sulphonal,  trional,  turpentine,  quinine, 
rhubarb,  and  senna. 

Fermentation  Test. — The  principle  of  this  method  is  based  on  the 
fact  that  glucose  is  decomposed  by  yeast  into  alcohol  and  carbon  dioxide. 
Special  fermentation  tubes,  as  designed  by  Einhorn,  are  convenient  in  con- 
ducting this  test.  The  method  is  carried  out  by  mixing  a  bit  of  a  cake  of 
compressed  yeast  with  urine  in  a  test-tube.  Einhorn 's  fermentation  tube 
is  filled  with  this  mixture,  care  being  taken  to  exclude  air  bubbles  from 


EXAMINATION  OF  THE  URINE.  303 

the  top  of  the  tube.  The  saecharometer  is  kept  at  a  temperature  of  from 
25 c  to  38°  for  twenty-four  hours,  during;  which  time  the  C02  collects 
in  the  upper  part  of  the  tube.  A  temperature  of  34°  C.  gives  the  most 
satisfactory  results.  A  control  test  should  always  be  made  with  normal 
urine,  since  slight  fermentation  occurs  in  every  specimen.  With  Einhorn's 
tube,  an  approximate  estimate  of  the  quantity  of  sugar  can  be  formed, 
but  for  accurate  quantitative  analysis  Robert's  differential  method  is  to 
be  preferred.  The  fermentation  test  serves  to  differentiate  fermentable 
sugar  from  other  reducing  substances. 

Quantitative  Estimation  of  Sugar.  Fehling's  Titration  Method. — 
Ten  c.c.  of  Fehling's  solution  diluted  with  40  c.c.  of  water  are  boiled.  At 
this  temperature  the  saccharine  urine  is  added  drop  by  drop  from  a  gradu- 
ated burette,  until  the  blue  color  of  the  test  solution  disappears,  which  indi- 
cates complete  reduction  of  cupric  oxide.  The  presence  of  reduced  copper 
held  in  suspension  obscures  the  color  of  the  solution,  so  that  it  is  necessary 
to  allow  the  cuprous  oxide  granules  to  settle  from  time  to  time  in  order  to 
detect  the  tint  of  the  fluid.  The  cupric  oxide  contained  in  10  c.c.  of  Fehling's 
solution  is  reduced  by  .05  gramme  of  glucose. 

Benedict's  Method. — The  estimation  is  based  upon  the  fact  that  a 
given  quantity  of  glucose  will  reduce  a  fixed  amount  of  copper  if  the  two 
are  combined  in  an  alkaline  solution.  The  solution  is  decolorized  and  the 
copper  precipitated  as  a  snow-white  compound — cuprous  sulphocyanate. 

The  reagent  is  prepared  as  follows : 

(1)  Dissolve  18  grains  of  pure  crystallized  copper  sulphate  in  100  c.c. 
of  water. 

(2)  Dissolve  by  the  aid  of  heat,  200  grammes  of  sodium  citrate,  200 
grammes  of  crystallized  sodium  carbonate  and  125  grammes  of  potassium 
sulphocyanide  in  800  c.c.  of  water. 

(3)  Mix  solutions  one  (1)  and  two  (2),  add  5  c.c.  of  a  5  per  cent, 
solution  of  potassium  ferrocyanide,  cool,  and  dilute  to  exactly  one  litre. 
The  solution  keeps  indefinitely. 

Technic. —  (1)  Dilute  10  c.c.  of  urine  with  water  to  100  c.c.  and  pour 
into  a  burette  to  the  zero  mark. 

(2)  Place  25  c.c.  of  the  reagent  in  a  porcelain  dish,  add  10  to  20  grains 
of  sodium  carbonate  (crystallized)  and  a  small  quantity  of  talcum  or  pumice. 
Heat  the  mixture  until  the  carbonate  is  dissolved. 

(3)  The  copper  solution  (2)  is  briskly  boiled  and  the  diluted  urine  in 
the  burette  is  run  into  the  boiling  solution  until  the  color  has  entirely 
disappeared.  This  marks  the  end  point.  If  the  solution  becomes  too  con- 
centrated a  small  amount  of  water  may  be  added. 

The  twenty-five  cubic  centimetres  of  copper  solution  are  reduced  by  50 
mg.  (0.050  gms.)  of  glucose. 

The  percentage  of  urine  is  determined  as  follows:  11^9.  y^  1000  —  per- 
centage  in  original  s;mi|>l<\  wherein  x  is  the  number  of  c.c.  of  the  diluted 
urine  required  to  reduce  25  c.c.  of  the  copper  solution.  The  daily  quantity 
of  the  urine  multiplied  by  percentage  gives  the  number  of  sugar  grammes 
for  the  day. 

Rohekt's    Dikkkkkn'tial    Density    Method. — The   principle    of    this 


304  MEDICAL  DIAGNOSIS. 

method  rests  on  determining  the  specific  gravity  before  and  after  fermenta- 
tion ;  each  .001  degree  of  difference  in  the  specific  gravity  represents  .23 
per  cent,  of  sugar.  The  test  is  carried  out  by  noting  the  specific  gravity  of 
200  c.c.  of  urine  taken  from  a  mixed  twenty-four-hour  specimen.  A  portion 
of  a  cake  of  compressed  yeast  is  mixed  with  the  urine,  which  is  then  set 
aside  for  twenty-tour  or  forty-eight  hours.  The  glucose  generally  disap- 
pears in  twenty-four  hours,  but,  in  order  to  ascertain  whether  all  the  sugar 
has  been  decomposed,  the  urine  is  tested  by  Fehling's  method.  After  all 
the  sugar  has  been  decomposed,  the  specific  gravity  of  the  fermented  urine 
is  taken  and  the  difference  between  the  two  readings  determined.  The 
small  urinometers  employed  in  clinical  work  are  not  suited  for  exact  determi- 
nation, therefore  it  is  convenient  to  use  larger  instruments.  Accurate 
estimations  can  be  taken  with  a  set  of  four  or  five  hydrometers,  each  of 
which  represents  a  part  of  the  specific  gravity  range  ordinarily  encountered 
in  diabetic  urine.  For  example,  hydrometer  number  1  indicates  the  scale 
from  1.000  to  1.010;  number  2  ranges  from  1.010  to  1.020;  number  3  ranges 
from  1.020  to  1.030;  number  4  ranges  from  1.030  to  1.040;  number  5  ranges 
from  1.040  to  1.050.  The  specific  gravity  observations  should  be  taken  at, 
or  nearly,  the  same  temperature.  Evaporation  of  the  urine  should  be 
reduced  to  a  minimum  during  fermentation.  The  first  specific  gravity 
determination  is  taken  before  the  yeast  is  added  to  the  urine,  and  the 
second  reading  is  made  after  the  fermented  urine  has  been  filtered. 

The  quantitative  determination  for  sugar  by  the  polariscope  is  recom- 
mended highly  by  many  workers.  A  polariscope  designed  for  this  estima- 
tion is  an  expensive  instrument,  The  rapidity  with  which  a  determination 
can  be  made  is  one  of  its  chief  advantages  over  other  methods. 

Physiological  Glycosuria. — The  presence  of  traces  (.5  pro  mille)  of 
glucose  in  the  urine  of  healthy  persons  is  conceded  by  most  authorities. 
This  quantity  cannot,  however,  be  detected  by  the  tests  employed  in  routine 
work. 

Pathological  Glycosuria. — This  condition  may  be  said  to  exist  when 
glucose  can  be  recognized  by  the  tests  generally  in  vogue  in  clinical  work. 
Glycosuria  may  be  transitory,  intermittent,  or  constant.  The  latter  variety 
is  one  of  the  cardinal  symptoms  of  diabetes  mellitus. 

Glycosuria  depends  directly  on  an  excess  of  sugar  (above  .2  per  cent.) 
in  the  blood.  A  possible  exception  to  this  rule  relates  to  the  glycosuria  fol- 
lowing the  administration  of  phloridzin.  It  is  thought  that  this  substance 
produces  such  alterations  in  the  renal  epithelium  as  to  permit  of  increased 
glucose  elimination.  A  renal  form  of  diabetes  has  been  suggested.  The 
sugar  of  the  blood  is  derived  principally  from  the  carbohydrates  of  the 
food,  and  in  all  likelihood  some  glucose  is  produced  from  the  albumins  of 
the  food.  In  certain  cases  of  diabetes,  characterized  by  rapid  emaciation, 
body  proteids  are  concerned  in  its  formation.  Although  many  factors 
involved  in  the  physiology  of  glucose  metabolism  remain  unexplained,  much 
clinical  and  experimental  evidence  supports  the  view,  (1)  that  sugar  metab- 
olism is  to  a  great  extent  regulated  by  the  nervous  system,  (2)  that  the  liver 
is  chiefly  concerned  in  converting  sugar  into  glycogen,  and  also  in  forming 
glucose,  and  (3)  that  the  pancreas  secretes  a  sugar-destroying  ferment.    A 


EXAMINATION  OF  THE  URINE.  305 

hypothetical  conception  of  pathological  glycosuria  based  on  this  theory 
may  be  said  to  depend  on  a  failure  on  the  part  of  the  liver  to  form  and 
store  up  glycogen,  a  disturbance  which  might  result  from  a  loss  of  nervous 
control  or  from  disease  of  the  hepatic  cells;  or  on  an  inability  on  the  part 
of  the  system  to  consume  sugar,  which  is  ascribed  to  a  disturbance  in  the 
function  of  the  pancreas  inhibiting  or  suppressing  the  secretion  of  the 
glycolytic  substance.  Clinically,  glycosuria  occurs  under  a  variety  of  cir- 
cumstances: Disorders  of  the  nervous  system.  Temporary  or  permanent 
glycosuria  is  observed  in  brain  tumors,  meningitis,  injuries  to  the  nervous 
system,  neurasthenia,  exophthalmic  goitre,  and  may  follow  worry,  fright,  or 
mental  overwork.  Diseases  of  the  pancreas.  Permanent  glycosuria  is 
often  associated  with  sclerosis,  and  sometimes  with  atrophy  or  tumors  of 
the  pancreas,  while  temporary  glycosuria  is  at  times  symptomatic  of  acute 
inflammation  of  this  organ.  Hepatic  disease,  abscess 
and  cirrhosis  of  the  liver  may  be  attended  with 
the  temporary  or  constant  presence  of  sugar  in 
the  urine.  Toxic  agents.  The  occasional  occur- 
rence of  glucose  in  the  urine  is  noted  in  the  infec- 
tious diseases,  as  syphilis,  influenza,  enteric  fever, 
diphtheria,  rheumatic  fever,  and  malaria,  and  from 
poisoning  by  chloral,  alcohol,  and  morphine.  The 
explanation  of  glycosuria  occurring  under  these  cir- 
cumstances might  be  found  in  the  development  of 
a  disorder  of  the  function  of  the  liver,  the  pancreas, 
or  the  nervous  system,  produced  by  these  toxic 
agents.    This  variety  is  mainly  observed  as  a  tran-      Fig.  121,— iodoform  crystals 

-,  x>  1,1  V  •  n       j-    i_    j  j  i  formed    from    the   distillate   of 

sitory  form,  although  occasionally  diabetes  develops   the  urine  of  a  case  of  diabetes, 
after  an  acute  infectious  disease,   which  suggests    "_Emerson- 
permanent  morbid  processes  of  the  hepatic  or  pancreatic  tissues  excited 
during  the  acute  stage  of  the  disease. 

The  power  possessed  by  the  system  to  consume  sugar  varies  in  health 
and  in  disease.  Carbohydrate  tolerance  can  be  determined  by  the  admin- 
istration of  glucose  by  the  mouth.  The  urine  of  healthy  persons  generally 
does  not  show  glucose  unless  the  amount  ingested  exceeds  250  grammes. 
When  glycosuria  follows  the  taking  of  100  grammes,  an  abnormal  sugar 
metabolism  probably  exists  (pathological  alimentary  glycosuria).  Carbo- 
hydrate tolerance  is  lessened  by  age,  and  is  often  reduced  in  obesity  and  gout. 

Lactose.— The  presence  of  milk  sugar  in  the  urine  is  indicated  by  a 
positive  reaction  with  Trommer's  and  Nylander's  tests  after  prolonged 
boiling,  when  negative  results  are  obtained  with  the  phenylhydrazine  and 
fermentation  tests.  Lactose  is  found  in  the  urine  during  the  last  weeks  of 
pregnancy  and  in  nursing  women.  Glycosuria  and  lactosuria  are  occa- 
sionally associated.  The  ingestion  of  more  than  120  grammes  of  lactose 
often  causes  a  lactosuria. 

Levulose. — The  presence  of  fruit  sugar  may  be  inferred  when  the  urine 
gives  sugar  reactions  with  Trommer's,  Fehling's,  the  fermentation  and 
phenylhydrazine  tests,  and  does  not  rotate  polarized  light  to  the  right. 
Levulose  at  times  rotates  polarized  light  to  the  Left.     Levulose  occurs  in 

20 


306  MEDICAL  DIAGNOSIS. 

the  urine  in  some  eases  of  diabetes  and,  at  times,  in  the  urine  of  healthy 
persons  after  the  ingestion  of  levulose. 

Pentose. — Pentose  can  be  recognized  by  the  fact  that  it  does  not  undergo 
fermentation  with  yeast,  but  gives  a  positive  reaction  with  Fehling's, 
Nylander's,  and  the  phenylhydrazine  tests.  Pentose  has  been  discovered  in 
the  urine  after  eating  plums,  pears,  apples,  cherries,  and  huckleberries, 
from  the  ingestion  of  50  grammes  or  more  of  pentose,  and  occasionally  in 
diabetes.    A  family  tendency  has  been  recorded. 

Dextrin. — This  substance  reduces,  Fehling's  solution,  the  copper  sepa- 
rating first  as  a  green,  then  changing  to  a  yellow  precipitate,  and  sometimes 
as  a  dark  brown  sediment.  Dextrin  has  been  found  in  the  urine  in  the 
absence  of  glucose.  Some  authorities  regard  the  presence  of  traces  of 
dextrin  as  normal. 

Acetone. — Legal 's  Test.— A  few  drops  of  freshly  prepared  concen- 
trated solution  of  sodium  nitroprusside  are  added  to  a  small  amount  of  uri- 
nary distillate,  and  the  mixture  treated  with  sodium  or  potassium  hydrate. 
When  a  ruby  color  develops,  rapidly  changing  to  yellow,  it  signifies  the 
presence  of  acetone.  This  test  is  usually  negative  with  mere  traces  of 
acetone. 

Lieben's  Test. — A  few  drops  of  potassium  hydrate  solution  and  a  small 
quantity  of  iodopotassic  iodide  are  added  to  the  urinary  distillate,  and 
the  mixture  warmed.  Acetone  is  indicated  by  the  formation  of  iodoform, 
which  appears  as  hexagonal  or  stellate  crystals,  and  can  be  recognized  by  its 
characteristic  odor. 

Gunning's  Test. — Tincture  of  iodine,  or  Lugol's  solution,  is  added  to 
the  urinary  distillate,  and  the  mixture  treated  with  ammonia  until  a  black 
precipitate  develops,  which  slowly  disappears,  leaving  a  yellow  deposit  of 
iodoform  crystals. 

Acetone  occurs  in  normal  urine  in  small  quantities,  not  exceeding  10 
mg.  in  twenty-four  hours.  It  is  increased  by  restricting  or  withholding 
carbohydrates  from  the  diet,  especially  when  large  amounts  of  proteids  are 
consumed.  It  is  also  augmented  in  febrile  diseases,  in  certain  cachexias,  in 
gastric  ulcer,  and  follows  the  administration  of  phloridzin,  and  chloroform 
narcosis,  and  in  severe  forms  of  diabetes  mellitus,  notably  before  and  dur- 
ing diabetic  coma. 

Diacetic  or  Aceto=acetic  Acid. — Gerhardt's  Test. — Ten  or  15  e.c.  of 
urine  are  subjected  to  the  action  of  a  solution  of  ferric  chloride.  When  a 
precipitate  forms  on  the  addition  of  the  ferric  chloride,  it  is  removed  by 
filtration,  and  to  filtrate  is  again  added  the  test  solution.  Diacetic  acid 
may  be  inferred  when  a  Bordeaux  red  color  develops,  which  may  completely 
disappear  in  from  twenty-four  to  forty-eight  hours.  Salicylic  acid,  salol, 
aspirin,  din  ret  in,  sodium  acetate,  and  antipyrin  may  give  a  similar  reaction. 
Prolonged  boiling  of  the  urine  containing  diacetic  acid  will  cause  a  complete 
or  partial  disappearance  of  this  substance. 

Diacetic  acid  is  rarely  found  in  normal  urine.  It  occurs  in  conjunction 
with  large  amounts  of  acetone,  and  the  clinical  significance  of  aceto-acetic 
acid  is  similar  to  that  of  acetone.  Oxybutyric  acid  may  also  be  associated 
with  diacetic  acid     Diaceturia  is  of  special  importance  in  diabetics,  since 


EXAMINATION  OF  THE  URINE.  307 

it  is  a  trustworthy  sign  of  acidosis,  and  is  always  a  forerunner  of  diabetic 
coma.  Aceto-acetic  acid  has  been  noted  in  the  urine  in  febrile  diseases,  in 
gastro-intestinal  disturbances,  especially  those  attended  with  starvation, 
and  occasionally  in  individuals  who  have  consumed  a  rich  proteid  diet  for 
a  number  of  days. 

/8-Oxybutyric  Acid. — The  urine  is  evaporated  to  the  consistency  of  a 
syrup,  and  an  equal  volume  of  concentrated  sulphuric  acid  is  added.  By 
distillation  crotonic  acid  is  obtained.  Crystals  of  crotonic  acid  separate 
on  cooling  the  distillate.  If  crystallization  does  not  occur  readily,  an 
ethereal  extract  is  obtained,  evaporated,  and  the  residue  dissolved  in  water 
and  allowed  to  crystallize.  The  presence  of  /?-oxybutyric  acid  may  be 
inferred  by  these  crystals.  If  fermented  diabetic  urine  containing  oxy- 
butyric  acid  be  subjected  to  polariscopic  examination,  polarized  light  is 
rotated  to  the  left. 

/5-Oxybutyric  acid  is  the  mother  substance  of  diacetic  acid,  while  ace- 
tone is  derived  from  the  latter  substance.  Its  presence  may  be  suspected 
when  diacetic  acid  exists  in  the  urine  in  large  amounts.  /3-oxybutyric  acid 
occurs  less  frequently  than  diacetic  acid  and  acetone,  and  in  general  terms 
may  be  said  to  arise  under  conditions  similar  to  those  causing  acetonuria. 
It  is  found  in  the  urine  in  severe  infectious  fevers,  during  starvation,  and 
in  grave  forms  of  diabetes.  /8-oxybntyric  acid  is  generally  regarded  as  the 
cause  of  diabetic  coma.  Some  attribute  the  symptoms  of  this  condition 
to  a  lowering  of  the  alkalinity  of  the  blood  (alkali  starvation),  others  con- 
tend that  its  toxic  action  is  responsible. 

Alkaptone  Bodies. —  The  urine  containing  alkaptone  bodies  reduces 
Fehling's  reagent,  causing  this  test  solution  to  blacken.  This  reaction 
serves  to  differentiate  it  from  glucose.  Nylander's,  the  phenylhydrazine  and 
the  fermentation  tests  are  negative  with  urine  containing  alkaptone  bodies. 

Urine  of  alkaptonuric  individuals  appears  normal  when  voided,  but 
on  standing  its  color  changes  to  a  reddish-brown  or  black.  This  peculiar 
characteristic  of  the  urine  is  thought  to  be  due  to  homogentisinic  acid  and 
uroleucinic  acid.  The  cause  of  this  condition  is  not  known.  The  condition 
is  compatible  with  good  health,  and  is  often  peculiar  to  several  members 
of  a  family,  but  inheritance  does  not  seem  to  be  an  important  factor  in  its 
production. 

Ehrlich's  Diazo  Reaction. — This  test,  introduced  by  Ehrlich,  depends 
on  certain  diazo  bodies,  which  probably  combine  with  aromatic  compounds, 
giving  a  color  reaction.  The  test  is  conducted  as  follows:  A  solution  con- 
sisting of  5  parts  of  sulphanilic  acid,  50  parts  of  hydrochloric  acid,  and  1000 
parts  of  water,  is  mixed  with  a  .5  per  cent,  solution  of  sodium  nitrite  in  the 
proportion  of  50  of  the  former  to  1  of  the  latter.  An  equal  volume  of  urine 
is  added  to  this  mixture  and  shaken.  Upon  the  addition  of  a  few  drops 
of  ammonia,  a  cherry-red  color  develops  at  the  zone  of  contact,  indicating 
a  positive  diazo  reaction.  On  shaking,  the  entire  iluid  becomes  red,  A 
brown  or  salmon  color  constitutes  a  negative  reaction.  The  chief  clinical 
significance  of  this  reaction  relates  to  its  almost  constant  presence  in 
eifteric  fever,  but  is  without  value  as  a  differential  sign,  since  it  occurs  in 
a  number  of  diseases.    It  is  frequently  present  in  measles,  ;unl  occasionally 


308  MEDICAL  DIAGNOSIS. 

in  pneumonia,  scarlet  fever,  diphtheria,  phthisis,  rheumatic  fever,  menin- 
gitis, and  at  times  in  non-febrile  diseases,  such  as  chronic  nephritis,  car- 
cinoma of  the  stomach,  and  leukasmia.  The  administration  of  salol,  phenol, 
and  betanaphthol  may  interfere  with  this  reaction. 

pat# — Normal  urine  does  not  contain  fat,  but  it  is  present  in  small 
amounts,  rarely  in  large  quantities  in  chronic  parenchymatous  nephritis, 
occasionally  when  fat  occurs  in  excessive  amounts  in  the  blood,  and  after 
the  administration  of  large  doses  of  cod-liver  oil.  It  has  been  observed 
in  bone  diseases  in  which  there  is  a  destruction  of  the  bone-marrow,  in 
diabetes  mellitus,  leukaemia,  pancreatic  diseases,  chronic  tuberculosis  of 
the  lungs,  and  obesity.  In  chyluria  or  galacturia  the  milky  appearance  of 
the  urine  is  due  to  fat  globules.  Chylous  or  chyliform  urine,  in  addition 
to  fat,  may  also  contain  leucocytes,  red  blood-cells,  fibrin,  albumin,  and 
occasionally  leucin,  tyrosin,  and  cholesterin. 

Quinine. — The  patient  is  to  pass  his  water  in  the  presence  of  a  doctor 
or  attendant.  To  2  c.c.  of  urine  in  a  test-tube  are  added  a  few  drops  of 
Tanret  's  solution.  If  the  urine  contains  quinine  it  immediately  assumes  an 
opalescent  appearance  which  is  marked  in  proportion  to  the  amount  of 
quinine  present.  The  same  reaction  occurs  with  alkaloids  and  albumin, 
but  disappears  in  either  case  upon  the  addition  of  a  few  drops  of  alcohol. 
The  test  is  extremely  sensitive  and  the  reaction  takes  place  about  two 
hours  after  the  ingestion  of  quinine  and  lasts  twenty-four  hours  after 
taking  quinine  and  reappears  during  twenty-four  hours,  even  when  small 
quantities  of  quinine  have  been  ingested,  and  as  long  as  forty-eight  hours 
with  1.50  or  2.00  gramme  doses.  This  test  is  important,  especially  in  mili- 
tary and  institutional  life,  for  the  following  reasons: 

(a)  To  ascertain  whether  or  not  a  patient  in  whom  symptoms  have  not 
been  relieved  has  actually  taken  the  daily  doses  dispensed  to  him. 

(b)  To  ascertain  whether  or  not  quinine  administered  in  pill  form  or 
capsules  has  actually  been  freed  in  the  intestines  or  dissolved. 

(c)  To  ascertain  in  a  case  where  sufficient  quinine  has  been  admin- 
istered for  the  proper  length  of  time  and  the  symptoms  are  not  relieved, 
whether  or  not  they  are  due  to  malaria. 

>  Cryoscopy  of  the  Urine. — The  determination  of  the  freezing  point  of 
the  urine  permits  one  td  measure  its  molecular  concentration.  The  appa- 
ratus devised  by  Beckmaim  is  generally  employed  in  ascertaining  the  freez- 
ing point.  The  average  freezing  point  in  normal  individuals,  as  determined 
by  Koranyi,  is  -1.7°  C,  although  wide  variations  are  noted.  Cryoscopy  of 
the  urine  is  rarely  employed  in  routine  clinical  work,  since  the  results  have 
not  been  satisfactory. 

Cammidge's  Test. — A  test  for  the  detection  of  pancreatic  disease  has' 
been  suggested  by  Cammidge.  He  holds  that  this  reaction  is  due  to  the 
presence  in  the  urine  of  a  peculiar  body,  probably  pentose.  For  the  details 
of  this  elaborate  procedure  the  reader  is  referred  to  the  manuals  on  special 
laboratory  work.  Cammidge  claimed  that  a  positive  reaction  occurs  in  all 
cases  of  active  inflammation  of  the  pancreas,  and  that  by  this  means  acute 
inflammation  of  the  pancreas  can  be  differentiated  from  intestinal  obstruc- 
tion, and  chronic  inflammation  of  the  organ  giving  rise  to  occlusion  of  the 


EXAMINATION  OF  THE  URINE.  309 

common  duet  can  be  diagnosticated  from  gall-stone  disease.  It  was  asserted 
also  that  "a  positive  reaction  is  indicative  of  altered  carbohydrate  metab- 
olism due  to  disturbance  of  the  internal  secretion  of  the  pancreas."  The 
enthusiasm  excited  by  this  announcement  was  followed  by  a  speedy  reaction. 

The  results  of  critical  studies  in  a  series  of  cases  at  the  Mayo  Clinic  in 
1911  justify  the  conclusion  that  "if  knowledge  of  the  clinical  histories  and 
other  factors  of  the  personal  equation  be  eliminated,  the  end  results,  judged 
by  Cammidge  's  own  criteria,  must  be  considered  as  a  means  of  diagnosing 
diseases  of  the  pancreas,  to  be  both  valueless  and  misleading.*'  Similar 
conclusions  followed  prolonged  and  careful  studies  in  the  surgical  clinic  of 
the  German  Hospital  in  Philadelphia  and  elsewhere.  It  has  been  shown  that 
rapid  disintegration  of  any  of  the  body  cells,  and  especially  of  the  poly- 
nuclear  leucocytes,  may  cause  the  reaction  in  the  urine. 

Phenolsidphonaphthalein  Test  for  Renal  Function. — See  page  636. 


310  MEDICAL  DIAGNOSIS. 


VII. 

THE  EXAMINATION  OF  THE  SPUTUM. 

Systematic  examination  of  the  sputum  furnishes  important  clinical 
data  in  a  considerable  group  of  diseases  (see  also  pp.  467-475). 

MICROSCOPICAL  EXAMINATION. 

Leucocytes. — The  mere  presence  of  leucocytes  has  no  special  signifi- 
cance, since  they  occur  in  every  specimen.  A  sputum  containing  an 
abundance  of  white  blood-corpuscles  generally  indicates  a  pathological 
disturbance  of  some  part  of  the  respiratory  tract,  as  chronic  bronchitis, 
bronchiectasis,  pulmonary  abscess,  tuberculosis  with  cavity  formation,  or 
may  be  due  to  a  rupture  of  an  extrapulmonary  purulent  collection  into 
the  lungs.  The  polynuclear  neutrophile  leucocytes  are  most  often  found  in 
sputum,  although  in  a  limited  number  of  diseases,  particularly  bronchial 
asthma,  eosinophils  are  noted.  The  sputum  in  asthma  is  usually  loaded 
with  eosinophils,  some  of  which  have  the  characteristic  morphology  and 
staining  reaction  of  the  hsemic  eosinophils,  while  others  are  supplied  with 
a  circular  nucleus.  In  certain  cases  of  bronchitis,  tuberculosis,  and  after 
haemoptysis,  eosinophiles  are  present  in  the  expectoration. 

Epithelial  Cells. — Every  specimen  of  sputum  contains  epithelial  cells. 
Pavement  epithelium  may  be  derived  from  the  mouth,  the  pharynx,  and 
the  upper  half  of  the  larynx,  while  cylindrical  cells  may  come  from  the 
nose,  the  lower  part  of  the  larynx,  trachea,  and  bronchi.  Catarrhal  inflam- 
mation, especially  in  its  early  stages,  generally  determines  the  presence  of 
large  numbers  of  epithelial  elements.  Ciliated  cells  are  occasionally  found 
in  asthma  and  acute  bronchitis,  provided  the  specimen  be  examined  im- 
mediately after  expectoration.  Alveolar  epithelial  cells  which  occur  in 
the  sputum  in  almost  every  pulmonary  disease,  as  well  as  in  the  "so-called" 
normal  expectoration,  are  large,  of  an  oval,  round,  or  polygonal  shape, 
supplied  with  one  or  several  relatively  small  vesicular  nuclei,  imbedded  in 
protoplasm  which  often  contains  albuminous  granules,  myelin  droplets, 
fat  globules,  particles  derived  from  haemoglobin,  or  coal  pigment.  These 
cells  occur  in  abundance  in  acute  inflammatory  pulmonary  disease  and 
tuberculosis.  Myelin  granules  have  an  irregular  outline,  often  present  a 
concentric  arrangement,  and  are  found  either  intra-  or  extracellularly. 
Myelin  probably  consists  mainly  of  protagon  and  of  small  amounts  of 
lecithin  and  of  cholesterin.  These  droplets  dissolve  in  alcohol,  stain  light 
yellow  with  iodine,  poorly  with  aniline  dyes,  and  are  not  blackened  with 
osmic  acid.  Alveolar  epithelium,  containing  granules  of  altered  blood 
pigment,  is  seen  in  the  sputum  of  congestion  of  the  lungs,  notably  in 
that  form  due  to  heart  disease,  hence  the  term  "heart  disease  cells"  is 
applied  to  them. 

Red  blood=celIs  occurring  in  small  numbers  are  commonly  observed 
in  the  sputum  of  many  diseases  of  the  respiratory  tract  and,  therefore,  have 


EXAMINATION  OF  THE  SPUTUM. 


311 


\\ 


---'■••■  t  *  - 


. .  -  u- 


£2L 


Fig. 


122. — Elastic  tissue  from  lung  showing  alveolar  arrange- 
ment.     X  50. — Emerson. 


no  special  importance,  but  when  present  in  considerable  or  large  numbers 
indicate  a  morbid  lesion.  Expectoration  of  blood  (haemoptysis)  is  due  to  a 
variety  of  causes  (see  page  458).  Erythrocytes  in  the  sputum,  as  a  rule,  ex- 
hibit alteration  of  structure,  so  that  crenated,  dehaemoglobinized,  and  frac- 
tured cells  are  common. 
Elastic  tissue,  in 
considerable  a  m oun t s , 
can  be  readily  demon- 
strated by  the  following 
method:  A  thin  layer  of 
sputum,  obtained  by 
pressing  it  between  two 
glass  plates,  is  examined 
with  the  aid  of  a  hand 
lens.  When  elastic  tissue 
cannot  be  recognized  by 
this  method,  the  microscope  should  be  employed;  a  suspected  particle, 
which  generally  has  a  gray  or  yellow  color,  is  placed  upon  a  slide  and 
studied  by  low  magnification.  Elastic  tissue  may  also  be  demonstrated 
by  treating  the  sputum  with  an  equal  quantity  of  a  10  per  cent,  solu- 
tion of  potassium  or  sodium  hydroxide  and  boiling  the  mixture  until 
it  becomes  homogeneous.  The  solution  is  shaken  with  four  or  five  parts 
of  water  and  the  mixture  centrifugated.  The  sediment  is  then  examined 
microscopically.  Elastic  tissue  is  found  as  long  slender  threads,  generally 
having  a  waxy  appearance,  and  at  times  these  fibres  conform  to  the 
outline  of  alveoli.     The  presence  of  elastic  fibres  indicates  disintegration 

of  bronchial  or  pulmonary  tissue,  the  latter 
being  positively  affirmed  when  the  fibres 
have  an  alveolar  arrangement.  Elastic 
tissue  is  noted  in  bronchiectasis,  pulmon- 
ary abscess,  gangrene,  tuberculosis,  and 
tumors  of  the  lungs. 

Curschmann's  spirals  are  noted  in 
the  sputum  in  cases  of  bronchial  asthma, 
occasionally  in  tuberculosis,  croupous 
pneumonia,  and  bronchitis.  Upon  micro- 
scopic examination,  they  consist  of  delicate 
twisted  threads,  often  wound  around  a 
central  core  Many  of  these  spirals  are  coated  with  mucus  in  which 
epithelial  cells,  eosinophiles,  neutrophile  leucocytes,  and  Charcot-Leyden 
crystals  are  imbedded.  Curschmann's  spirals  consist  chiefly  of  mucus, 
while  the  central  core  is  held  to  be  fibrin  in  some  instances.  Many  author- 
ities claim  that  these  bodies  are  formed  in  the  bronchioles. 

Crystals. — With  the  exception  of  Charcot-Leyden  crystals,  very  little 
importance  can  as  yet  be  attached  to  the  presence  of  crystalline  bodies. 
Charcot-Leyden  crystals  arc  colorless  and  have  the  shape  of  two  elongated, 
sharply  pointed,  hexagonal,  pyramidal  figures  with  bases  opposed.  They 
stain  with  eosin.  ft  was  formerly  thought  that  they  were  the  exciting 
factor  of  bronchial  asthma.     This  view  is  no  longer  entertained,  since  these 


^  H 


tlie  spul  uni  of  a  ca>e  < jf  asthma. 
Emerson. 


2UU.— 


312  MEDICAL    DIAGNOSIS. 

crystals  are  occasionally  found  in  other  diseases,  such  as  bronchitis  and 
tuberculosis.  They  are  probably  formed  from  eosinophile  cells.  Crystals 
of  fatty  acids  are  noted  in  the  sputum  of  tuberculosis,  gangrene,  bron- 
chiectasis, and  fetid  bronchitis.  Cholesterin  plates,  which  are  rarely 
seen  in  the  sputum,  have  been  found  in  conjunction  with  fatty  acid  crystals 
in  abscess  of  the  lung,  and  phthisis.  H^ematoidin  crystals  occur  in  the 
putrid  sputum  of  certain  lung  diseases,  and  in  empyema  and  hepatic  abscess 
with  a  bronchial  outlet,  and  occasionally  after  haemoptysis.  Leucin  and 
tyrosin  crystals  are  at  times  present  in  purulent  sputum,  while  calcium 
oxalate   and   triple   phosphate   crystals   are   rare   ingredients   of  sputum. 

Animal  Parasites — The  Trichomonas  pulmonalis  has  been  reported 
in  a  few  instances  in  the  sputum  in  lung  gangrene,  tuberculosis,  abscess, 
and  putrid  bronchitis,  while  circomonads  have  been  recorded  in  pul- 
monary gangrene.  The  sputum  in  cases  of  liver  abscess  perforating  into 
the  lung  may  show  the  Amceba  coli.  Taenia  Echinococcus. — Hydatid 
disease  may  cause  pulmonary  abscess  or  gangrene  and  is  sometimes  re- 
sponsible for  copious  haemoptysis.  The  sputum  in  this  condition  may 
contain  shreds  of  cyst  membrane,  daughter  cysts,  scolices  and  hooklets 
of  the  worm.  Distoma  Pulmonale. — This  parasite  is  responsible  for  a 
form  of  chronic  pulmonary  disease,  characterized  by  haemoptysis,  seen  in 
Japan,  China,  and  Korea.    This  fluke  and  its  ova  are  found  in  the  sputum. 

Vegetable  Parasites. — A  large  number  of  micro-organisms  have  been 
found  in  the  sputum.  Among  these  may  be  mentioned:  the  tubercle 
bacillus,  Diplococcus  pneumoniae,  staphylococci,  streptococci,  sarcinae, 
streptothrix,  actinomyces,  Micrococcus  catarrhalis,  and  the  influenza, 
smegma,  typhoid,  plague,  diphtheria,  and  Friedlander's  bacillus. 

In  the  case  of  tubercle  bacilli,  their  staining  reaction,  outline,  and 
size,  in  the  absence  of  biological  tests,  generally  afford  sufficient  evidence 
to  establish  the  diagnosis  of  this  organism.  With  most  bacteria  occur- 
ring in  the  sputum  this  is  not  the  case,  so  that  their  identity  can  only 
be  determined  provisionally  but  not  finally  by  their  tinctorial  and  mor- 
phological characteristics.  This  tentative  opinion  is,  however,  often 
strengthened  by  the  correlation  of  the  clinical  data  of  the  underlying 
pathological  process.  Cultural  studies  are  as  a  rule  essential,  and  inocula- 
tion experiments  often  i-equired  for  a  bacteriological  diagnosis.  Works  on 
bacteriology  should  be  consulted  for  bacteriological  investigations. 

Tubercle  Bacillus. — The  finding  of  tubercle  bacilli  in  the  sputum 
is  a  valuable  sign  in  establishing  the  diagnosis  of  tuberculosis  of  the  lungs, 
although  the  absence  of  these  organisms  in  the  expectoration  of  an  individ- 
ual presenting  pulmonary  symptoms  does  not  necessarily  negative  the 
diagnosis.  The  failure  to  find  bacilli  on  a  number  of  examinations  in  a 
suspected  case,  particularly  of  a  chronic  nature,  is  strong  evidence  against 
the  existence  of  phthisis.  In  acute  tuberculosis,  especially  in  the  early 
stages,  they  are  frequently  wanting  in  the  sputum.  There  is  no  single 
characteristic  presented  by  macroscopic  examination  of  the  sputum  by 
which  its  tuberculous  nature  can  be  recognized.  Rosenberger  holds  the 
view  based  on  repeated  observations  that  tubercle  bacilli  are  present 
in  the  faeces  of  persons  suffering  from  active  pulmonary  tuberculosis,  even 
in  the  acute  miliary  form.     The  technic  of  the  examination  for  tubercle 


PLATE  VI. 


•» 

. 

*  41  • "~ 

V 

^ 

^^* 


•.ft 


*        *      * 


■  ie  bacilli  in  sputum  stained  with  carbo]  fuchsin and  Pappenheim's  reagent. 


EXAMINATION    OF  THE   SPUTUM.  313 

bacilli  is  as  follows:  Preferably  a  caseous  mass  or  a  bit  of  purulent  or 
hemorrhagic  sputum  is  placed  upon  a  slide  or  cover-slip.  In  the  absence  of 
cheesy  particles,  specimens  are  selected  from  different  parts  of  the  sputum. 
A  thin  smear  is  made,  carefully  dried  and  fixed  by  rapidly  passing  the 
slide  or  cover-glass  through  a  flame  several  times.  The  tubercle  bacillus 
belongs  to  the  group  of  acid-fast  bacteria,  which,  after  staining,  resist  to 
a  marked  degree  decolorization  with  solutions  of  mineral  acids. 

To  concentrate  the  bacteria  in  the  specimen  of  the  sputum,  the 
method  of  Mulhauser-Czaplewski  will  be  found  most  serviceable.  From 
four  to  eight  volumes  of  a  0.25  per  cent,  solution  of  sodium  hydrate  are 
added  to  the  sputum,  placed  in  a  bottle,  and  shaken  until  the  fluid  has  a 
uniform  mucilaginous  appearance.  A  few  drops  of  phenol-phthalein  solu- 
tion are  added  and  the  liquid  is  boiled.  A  2  per  cent,  solution  of  acetic  acid 
is  no.w  added  drop  by  drop  until  the  pink  color  of  the  liquid  just  disap- 
pears.   The  material  can  now  be  centrifugated  and  the  sediment  examined. 

Antiformin. — To  a  portion  of  sputum  in  a  centrifuge  tube  add  an  equal 
amount  of  a  10-15  per  cent,  solution  of  antiformin;  allow  it  to  stand  for 
a  few  minutes  and  then  centrifugate.  Decant  the  supernatant  antiformin 
solution  and  again  centrifugate.  At  this  point  a  few  cubic  centimetres  of 
alcohol  may  be  added  to  lower  the  specific  gravity  and  aid  in  the  precipi- 
tation of  the  bacilli.  The  sediment  is  then  smeared  on  the  slide  and  stained 
by  one  of  the  usual  methods. 

Ziehl-N edsen  Method. — The  stain  consists  of  10  c.c.  of  a  concentrated 
alcoholic  solution  of  fuchsin,  dissolved  in  90  c.c.  of  a  5  per  cent,  solution 
of  carbolic  acid.  The  film  of  sputum  is  covered  with  the  stain.  The  cover 
or  slide  is  then  held  over  a  flame  until  the  solution  is  brought  to  the  boil- 
ing point;  or  the  specimen  may  be  stained  in  cold  carbol  fuchsin  for  24 
hours.  After  a  half  minute,  the  excess  of  hot  stain  is  poured  off  and  the 
specimen  washed  with  water.  *The  stained  preparation  is  next  placed  in 
a  25  per  cent,  solution -of  nitric  acid  for  several  seconds  until  the  bright 
red  color  disappears,  then  washed  in  water  and  dried.  The  specimen  may 
be  counterstained  with  a  watery  solution  of  Bismarck  brown  or  methylene 
blue  for  a  minute  or  two.  The  cover-glass  film  is  mounted  on  a  slide  in 
balsam  or  cedar  oil.  The  specimen  spread  and  stained  upon  a  slide,  the 
most  convenient  method,  may  be  examined  without  a  cover-glass. 

Gabbett's  Method. — The  sputum  properly  spread  and  fixed  upon  a  slide 
or  cover-glass  is  covered  with  a  reagent  consisting  of  fuchsin  1  gramme, 
alcohol  10  cubic  centimetres,  and  a  5  per  cent,  solution  of  carbolic  acid  100 
cubic  centimetres,  and  held  over  a  flame  until  the  stain  boils.  After  drain- 
ing off  the  carbol  fuchsin  from  the  slide,  the  specimen  is  treated  for  two 
minutes  with  Gabbett's  reagent,  composed  of  methylene  blue,  2  parts,  dis- 
solved in  100  parts  of  a  25  per  cent,  solution  of  sulphuric  acid;  then  washed 
with  water,  thoroughly  dried,  and  examined  microscopically. 

Pappenheim's  Method.  —  This  method  affords  the  means  of  dis- 
tinguishing tubercle  bacilli  from  other  acid-fast  organisms.  The 
stain  is  prepared  by  dissolving  1  part  of  corallin  in  100  parts  of 
absolute  alcohol.  This  solution  is  then  saturated  with  methylene  blue, 
after  which  20  parts  of  glycerin  are  added.  After  staining  the  specimen 
with  a  heated  carbol  fuchsin  solution  in  the  manner  previously  described, 


314  MEDICAL  DIAGNOSIS. 

the  excess  of  stain  is  drained  from  the  slide  and  immediately  Pappenheim's 
solution  is  placed  upon  it  and  allowed  to  act  for  a  few  minutes.  Fresh 
solutions  may  be  added  several  times  if  the  spread  is  tinged  red  in  any 
part.     The  slide  is  next  washed  in  water,  dried,  and  examined. 

With  these  methods,  tubercle  bacilli  appear  as  straight  or  slightly 
bent  red  rods,  varying  from  1.5  to  4  microns  in  length  and  from  .1  to  .2 
micron  in  thickness.  Occasionally  they  are  tinted  more  deeply  in  certain 
parts,  having  the  appearance  of  a  streptococcus  (beaded  forms).  Branch- 
ing forms  are  rarely  found.  The  older  varieties  of  bacilli  are  thought  to 
tain  more  intensely  than  the  younger  forms.  As  a  rule  a  number  of  organ- 
isms can  be  found  in  preparations,  many  of  which  are  frequently  arranged 
in  groups  containing  several  or  more  organisms.  It  is  most  uncommon  to 
find  but  a  single  bacillus  in  a  specimen  and,  when  this  occurs,  the  possi- 
bility of  contamination  of  the  sputum  from  dust  should  be  remembered. 
The  number  of  germs  in  chronic  cases  often  is  an  index  to  the  extent  of 
the  ulceration  in  the  lung,  although,  in  acute  cases,  the  degree  of  the  tuber- 
cle involvement  bears  no  relation  to  the  abundance  of  bacilli.  A  lessening 
in  the  number  of  bacilli  ofttimes  is  associated  with  a  steady  improvement 
in  the  patient,  and  a  disappearance  of  the  micro-organisms  frequently 
points  to  quiescent  or  healed  lesions. 

Diplococcus  Pneumonia. — The  finding  of  pneumococci  in  the  sputum, 
in  the  absence  of  other  clinical  data,  is  without  diagnostic  significance, 
since  these  organisms  exist  in  the  saliva  of  a  considerable  proportion  of 
healthy  individuals,  as  well  as  in  the  expectorated  material  in  several 
diseases.  Their  presence  in  the  sputum  of  a  case  exhibiting  pulmonary 
symptoms  often  establishes  an  etiological  diagnosis.  Pneumococci  are 
found  in  large  numbers  in  the  sputum  of  croupous  pneumonia  and  occa- 
sionally in  bronchopneumonia.  This  organism  reacts  positively  to  solutions 
of  basic  dyes.  Stained  specimens  frequently  show  a  colorless  capsule 
about  the  diplococci. 


VIII. 

THE  EXAMINATION  OF  TRANSUDATES,  EXUDATES,  AND  THE 

CONTENTS  OF  CYSTS. 

The  results  of  the  examination  of  transudates,  exudates,  and  the 
contents  of  cysts  by  physical,  chemical,  microscopical,  and  bacteriologi- 
cal methods  are  diagnostic  auxiliaries. 

Exploratory  Puncture. — An  exploratory  syringe,  equipped  with  a 
large  stout  needle,  is  generally  used  for  this  purpose,  but  for  some  explora- 
tions the  aspirator  needle  alone  is  employed,  since  the  positive  internal 
pressure  of  certain  effusions  expels  the  fluid.  The  operation  of  explora- 
tory puncture  must  be  performed  under  strict  antiseptic  precautions; 
the  skin  should  be  sterilized  by  thoroughly  scrubbing  with  soap  and  hot 
sterilized  water,  followed  by  washing  with  hot  sterilized  water  and  then 


TRANSUDATES,  EXUDATES,  AND  CYST  CONTENTS.       315 

with  an  antiseptic  solution.  When  possible  an  antiseptic  dressing  should 
be  applied  for  some  hours  prior  to  performing  the  operation.  The  hands 
of  the  operator  should  be  surgically  clean  and  the  instrument  should  be 
sterile.  The  technic  of  peritoneal,  pleural,  pericardial,  and  lumbar  punc- 
ture is  discussed  in  Part  IV. 

The  differentiation  between  exudates  and  transudates  is  not,  as  a  rule, 
difficult,  since  the  internist  is  guided  by  associated  clinical  phenomena  in 
determining  the  origin  of  the  fluid.  There  are,  however,  cases  in  which 
the  character  (whether  it  be  inflammatory  or  non-inflammatory)  of  the 
material  cannot  be  ascertained  by  the  symptoms  or  the  history  of  the  case, 
and  the  final  distinction  must  rest  with  the  laboratory,  although  in  a  few 
instances  the  various  methods  of  laboratory  research  fail  to  solve  the 
problem. 

Transudates  are  generally  light  yellow  or  pale  yellowish-green,  at  times 
reddish,  due  to  blood  staining,  milky  as  noted  in  chylous  effusions,  and 
dark  yellow  when  deeply  tinged  with  biliary  pigment. 

The  composition  of  transudates  of  the  peritoneal,  pleural,  and  peri- 
cardial sacs  is  nearly  the  same.  They  consist  of  water  (95-96  per  cent.), 
solids,  proteids,  extractives,  inorganic  salts,  and  uric  acid.  Allantoin. 
dextrose,  fructose,  urobilin,  and  biliary  pigment  have  also  been  demon- 
strated in  transudates.  Their  specific  gravity  is  generally  below  1.018,  in 
many  cases  as  low  or  even  below  1.010,  and  occasionally  above  1.020.  Hy- 
dremic transudates  are  of  lighter  specific  gravity  than  those  due  to  stasis. 
The  specific  gravity  is  influenced  mainly  by  the  proteids  contained  in  the 
fluid,  so  that  exudates,  which  are  generally  richer  in  albuminous  bodies 
than  dropsical  fluids,  are  as  a  rule  of  higher  gravity  than  transudates. 
The  estimation  of  the  total  proteids  content  is  therefore  of  value  in  dif- 
ferentiating between  transudates  and  exudates.  The  percentage  of  pro- 
teids in  stasis  transudates  generally  ranges  from  1  to  3,  while  in  hydremic 
effusion  it  is  much  lower,  usually  not  above  .5.  Transudates  either  contain 
no  fibrin  or  it  exists  only  in  minute  amounts.  A  few  endothelial  cells  and 
leucocytes,  at  times  erythrocytes  and  cholesterin  crystals,  are  found. 
In  hydroperitoneum  occurring  in  leukaemia.  Charcot-Leyden  crystals, 
mast  cells,  and  eosinophiles  bave  been  recorded.  In  the  main  the  chlorides 
exist  in  greater  concentration  in  transudates  than  in  exudates,  and  as  a 
rule  the  degree  of  alkalinity  of  dropsical  fluids  is  about  that  of  the  blood  of 
the  individual  in  question,  while  in  an  exudate  it  is  lowered. 

Exudates. — The  chief  varieties  of  exudates  are  serous,  hemorrhagic, 
purulent,  and  putrid,  and  between  these  types  there  are  gradations  and 
combinations.  The  recognition  by  macroscopic  inspection  of  purulent 
collections  is  generally  a  simple  matter,  although  serous  exudates,  which 
contain  a  large  number  of  fine  fibrin  flakes  and  chylous  fluids,  are  of  similar 
appearance.  The  uniform  turbidity  of  purulent  effusions  serves  to  dis- 
tinguish them  from  serofibrinous  effusions,  while  the  presence  of  fine 
granules  of  fat  is  characteristic  of  chylous  fluids.  In  many  inflammatory 
collections  a  coagulum  forms  immediately  after  the  fluid  is  withdrawn 
from  the  burly.  Their  specific  gravity  is  generally  above  1.018,  the  proteid 
content  is  usually  above  1  per  cent,  and  at  times  as  high  as  6  per  cent. 
Serum  albumin  and  globulin  in  considerable  amounts,  traces  of  fibrinogen 


316  MEDICAL  DIAGNOSIS. 

and  serosamucin  are  present  in  exudates;  nucleo-albumin,  albumoses, 
leucin,  and  tyrosin  have  also  been  noted. 

Rivalta's  Test. — The  principle  of  this  test  is  based  on  the  precipita- 
tion in  many  exudates  of  a  peculiar  body,  the  character  of  which  has  not 
been  definitely  determined,  although  regarded  by  some  authorities  as  mucin 
and  denominated  serosamucin,  while  others  hold  that  it  is  a  globulin. 
This  test  is  carried  out  by  allowing  a  drop  of  the  fluid  to  fall  into  a  weak 
acetic  acid  solution  (two  drops  of  glacial  acetic  acid  in  100  c.c.  of  distilled 
water).  When  the  drop  sinks  and  leaves  a  turbidity  it  indicates  the  pres- 
ence of  this  substance,  while  the  failure  to  produce  cloudiness  denotes  the 
absence  of  this  body  (serosamucin).  The  intensity  of  the  cloudiness  and 
the  rapidity  with  which  it  forms  are  an  index  to  the  amount  present.  This 
test  is  of  importance  in  differentiating  exudates  from  transudates. 

Animal  parasites,  bacteria,  many  cellular  elements,  lymphocytes,  poly- 
nuclear  cells,  endothelial  cells,  erythrocytes,  and  detritus  occur  in  exudates. 

Bacteriological  Examination.  —  Bacteria'  rarely  exist  in  transu- 
dates, but  their  presence  in  exudates,  which  is  frequent,  furnishes  a  most 
useful  field  for  diagnosis  and  prognosis.  The  fluid  for  bacteriological 
examination  is  collected  in  a  sterile  flask,  the  neck  of  which  is  then  immedi- 
ately plugged  with  sterile  cotton.  (For  technic  consult  works  on  bacteriol- 
ogy.)     A  diagnosis  of  tubercle  bacilli  can  often  be  made  by  staining  methods. 

Collecting  Sediment.- — Fluids  removed  by  puncture  often  coagulate 
spontaneously.  Since  the  coagulum  entangles  some  of  the  cellular  bodies 
and  bacteria,  the  elements  which  remain  in  the  fluid  portion  do  not  form 
an  accurate  basis  for  calculating  the  number  or  the  percentages  of  the  dif- 
ferent varieties  of  cells.  In  order  to  prevent  coagulation  one-third  or 
fourth  volume  of  a  2  per  cent,  sodium  citrate  salt  solution  is  added  to  the 
specimen.  After  centrifugalization  or  sedimentation  the  supernatant  fluid 
is  removed  and  the  tube  is  filled  with  saline  solution,  then  gently  agitated 
and  recentrifugated.  Much  of  the  albumin  is  removed  from  the  fluid  by 
this  procedure,  which  insures  better  results  in  staining. 

Inoscopy,  the  method  introduced  by  Jousset,  was  designed  to  aid  in 
the  diagnosis  of  tuberculosis.  The  exudate  is  allowed  to  coagulate  spon- 
taneously, but  should  this  not  occur  the  addition  of  horse  serum  will  bring 
about  clotting.  The  coagulum  which  holds  many  of  the  tubercle  bacilli 
is  then  removed,  broken  up,  and  digested  by  means  of  a  fluid  consisting  of 
NaF  3  grammes,  pepsin  1  or  2  grammes,  glycerin  10  c.c,  HC1  40  per  cent. 
15  c.c,  water  1000  c.c.  The  resulting  liquid  is  then  centrifugated  and  the 
sediment  examined  in  the  usual  manner  for  tubercle  bacilli. 

Cytological  Examination.  —  After  securing  the  sediment  of  the 
citrated  material,  or  the  digested  coagulum,  it  should  be  properly  fixed. 
Treating  the  sediment  with  a  |  or  1  per  cent,  formaldehyde  solution  for 
several  minutes  is  highly  recommended  by  some  workers.  The  sediment 
is  spread  into  a  thin  film  upon  a  slide  or  cover-glass,  dried,  and  if  not  pre- 
viously fixed  is  now  subjected  to  such  fixatives  as  methjd  alcohol,  or  alcohol 
and  ether,  heat,  or  formalin  solutions.  The  selection  of  the  stain  depends 
upon  the  structures  desired  to  be  demonstrated  and  upon  the  choice  of 
the  worker.  Most  of  the  Romanowsky  modifications  or  double  stains,  as 
eosin  and  haematoxylon  or  methylene  blue,  give  satisfactory  results.     The 


TRANSUDATES,  EXUDATES,  AND  CYST  CONTENTS.      317 

principle  which  involves  the  determination  of  the  percentages  of  the  vari- 
ous types  of  cells  is  the  same  as  for  the  differential  counting  of  leucocytes. 
Immediate  citration  of  fresh  specimens,  followed  by  centrifugating,  prob- 
ably offers  the  best  means  of  studying  cellular  elements  and  bacteria. 

Cytodiagnosis. — The  cytological  formula  does  not  diagnose  a  disease, 
but  rather  suggests  the  acuteness  or  chronicity  of  a  pathological  condi- 
tion, the  stage  and  intensity  of  a  morbid  process,  or  the  absence  of  inflam- 
mation. A  rare  exception  relates  to  effusions  which  contain  tumor  frag- 
ments, the  histology  of  which  may  be  diagnostic. 

The  most  important  cellular  elements  entering  into  cytological  studies 
are  lymphocytes,  polynuclear  cells,  endothelial  cells,  eosinophile  cells,  mast 
cells,  erythrocytes,  and  tumor  cells. 

Endothelial  Cells. — An  increase  of  endothelial  cells  in  a  fluid  is  gen- 
erally associated  with  non-inflammatory  effusions  of  the  serous  cavities. 
Dropsical  effusion  due  to  passive  congestion  and  hydremic  transudates 
shows  endotheliocytosis.  In  the  early  stages  of  a  tuberculous  effusion  a 
high  percentage  of  endothelial  elements  is  sometimes  noted. 

Lymphocytes.  —  An  irritant  of  mild  intensity  is  responsible  for  a 
lymphocyte  predominance  in  an  effusion.  Such  a  reaction  is  essentially 
local  and  does  not  provoke  a  general  stimulus.  An  irritation  of  low  grade, 
especially  when  protracted  over  a  long  period,  calls  forth  these  cells.  Lym- 
phocytosis is  the  rule  in  tuberculosis,  although  a  polynucleosis  may  precede 
a  lymphocytic  phase,  or  in  some  instances  it  may  follow.  These  variations 
are  attributed  to  increased  virulence  of  bacteria  and  to  secondary  or  mixed 
infections.  A  lymphocyte  preponderance  preceded  by  a  polynucleosis  is 
regarded  as  having  a  favorable  prognostic  significance.  The  development 
of  a  polynucleosis  taking  the  place  of  a  lymphocytosis  is  suggestive  of  a 
complication.  In  the  late  stages  of  acute  inflammations  or  when  these  tend 
to  become  chronic,  a  high  lymphocyte  percentage  is  often  noted.  Lym- 
phocytosis is  noted  almost  constantly  in  effusions  of  tuberculous  origin 
and  sometimes  in  those  due  to  syphilis,  uraemia,  malignant  tumors,  and 
paresis. 

Polynuclear  Cells. — The  exudates  in  acute  inflammation  or  infections 
of  serous  sacs,  such  as  are  produced  by  staphylococci,  pneumococci,  strep- 
tococci, meningococci,  colon  bacilli,  and  typhoid  bacilli,  contain  a  high 
percentage  of  polynuclear  leucocytes.  In  the  early  stage  of  tubercu- 
losis a  polynucleosis  is  sometimes  noted,  and  frequently  in  tuberculosis 
pericardia]  effusions.  As  an  acute  inflammation  subsides  polynuclear 
preponderance  becomes  less  marked,  and  this  is  often  followed  by  a  rise 
in  the  Dumber  of  the  Lymphocytes,  which  may  outnumber  the  multinuclear 
elements. 

Eosinophilic  cell  increase  has  been  recorded  in  effusion  occurring  in 
the  course  of  rheumatic  fever,  tuberculosis,  nephritis,  syphilis,  carcinoma, 
and  following  trauma. 

Mast   cells  have   been    noted   occasionally    in   effusions,   especially   those 

of  long  standing. 

Erythrocytes. — Contamination  of  the  fluid  with  blood  from  the  wound 


318 


MEDICAL  DIAGNOSIS. 


made  by  puncture  is  unavoidable  in  many  instances,  but  aside  from  this 
source  red  corpuscles  in  an  effusion  are  at  times  the  expression  of  malig- 
nant, renal,  or  tuberculous  disease.  They  are  also  seen  in  effusion  due  to 
acute  infections.  They  may  be  seen  in  acute  leukaemia  and  the  blood  dys- 
pasias. The  possibility  of  a  hemorrhage,  as  in  cerebral  apoplexy  with 
effusion  into  the  ventricles  of  the  brain,  or  a  small  leak  of  an  aneurism 
into  a  serous  sac,  should  always  be  borne  in  mind. 

The  recognition  of  some  of  the  varieties  of  cells  just  described  may  not 
be  so  simple  a  matter.  A  cell  having  a  single  nucleus  undergoing  degenera- 
tion and  fragmentation  ma}^  resemble  a  multinuclear  element.  Polynuclear 
cells  may  be  difficult  to  detect  when  the  cell  body  undergoes  shrinkage 
and  becomes  disintegrated. 

Chylous  fluids  owe  their  turbidity  to  fine  particles  of  fat.  The  amount 
of  fat  varies;  it  is  often  under  1  per  cent.,  but  in  a  case  reported  by  Hammer- 
fahr  it  reached  2.95  per  cent.  Other  constituents  of  this  variety  of  effu- 
sion are  water  (90  per  cent.  +),  albumin,  fibrin,  globulin,  cholesterin, 
lecithin,  salts,  soaps,  fatty  acids,  and  other  substances.  The  fat  is  soluble 
in  ether  and  gives  the  tests  for  this  substance. 

There  are  certain  effusions  designated  chyloid  or  pseudochylous  which 
closely  resemble  chylous  fluids  in  their  gross  appearance  but  differ  from 
them  since  the  free,  fine,  fat  particles  are  absent.  The  opalescence  of  these 
fluids  probably  depends  on  a  variety  of  causes,  while  in  some  instances 
the  milky  appearance  cannot  be  explained.  The  presence  of  endothelial 
or  epithelioid  cells  with  a  fatty  degenerated  protoplasm  is  the  explanation 
suggested  by  Quincke  in  some  of  these  cases.  Other  observers  hold  that 
bacteria,    globulins,    lecithin,    mucin,    and    certain    proteids    (other    than 

globulin)  are  responsible  for  the  turbidity 
which  may  in  some  instances  suggest  a  puru- 
lent character  rather  than  a  milky  appearance. 
Chylous  collections  are  not  uncommonly 
noted,  especially  in  the  peritoneal  cavity  and 
pleural  sacs,  rarely  in  the  pericardium.  These 
effusions  arise  in  a  number  of  diseases  in  which 
pressure  is  exerted  on  the  thoracic  duct  or  the 
lymphatic  vessels. 

Cerebrospinal  Fluid. — In  health  the  cere- 
brospinal fluid  obtained  by  lumbar  puncture 
is  colorless,  clear,  of  alkaline  reaction,  has  a 
low  specific  gravity,  ranging  from  1.003  to 
1.007  clue  to  the  presence  of  from  1  to  1.5  per 
cent,  of  solids  and  cellular  elements  (endothelial 
cells  and  leucocytes),  not  exceeding  5  per  c. 
mm.  The  amount  under  normal  conditions 
has  been  set  as  varying  between  5  and  10  c.c. 
although  these  figures  are  only  approximate.  The  dural  pressure  as  deter- 
mined with  an  ordinary  water  manometer  in  the  dorsal  position  ranges 
from  60  to  100  mm.  in  health,  while  in  disease,  as  in  meningitis  and  cere- 
bral tumor,  it  may  reach  from  200  to  800  mm.  Serious  symptoms  may 
arise  on  withdrawing  the  fluid  when  the  pressure  falls  below  60  mm. 


?**      ' 

«s^  ^ . 

'     dft^'U*  ^  w  ^  *J 

._   _JL%*%« 

Fig.  124. — Smear  of  the  spinal 
fluid  of  a  case  of  epidemic  cerebro- 
spinal meningitis. — Emerson. 


TRANSUDATES,  EXUDATES,  AND  CYST  CONTENTS.       319 

Urea,  globulin,  protalbumose,  nucleoproteid,  and  a  reducing  substance 
probably  similar  to  pyrocatechin,  and  sodium  chloride  and  other  inorganic 
salts  are  present.  Serum  albumin  is  said  never  to  exist  in  the  normal 
fluid.  There  is  some  doubt  as  to  the  presence  of  glucose;  some  author- 
ities claim  that  it  is  a  normal  constituent  (.4  to  .5  per  cent.),  which  dis- 
appears when  meningitis  develops  (Lannois  and  Boulard),  while  others 
hold  that  it  does  not  exist  in  health. 

In  pathological  conditions  the  cerebrospinal  fluid  is  often  altered. 

In  disease  the  quantity  varies  from  a  few  c.c.  to  more  than  100  c.c. 
The  amount  is  increased  in  acute  hydrocephalus,  in  general  paresis,  dementia 
prsecox.  in  some  of  the  infectious  diseases,  in  brain  tumors,  and  in  menin- 
gitis. It  should  be  borne  in  mind  that  interference  with  the  circulation  of 
the  cerebrospinal  fluid  from  increased  intracranial  pressure,  as  in  brain 
tumor,  which  cuts  off  the  communication  between  the  subarachnoid 
basilar  spaces  of  the  brain  and  those  of  the  cord,  may  result  in  an  absence 
or  diminished  amount. 

The  fluid  is  often  pale  yellow,  cloudy,  or  creamy  in  appearance  in  acute 
meningitis,  while  in  tuberculous  meningitis,  hydrocephalus,  and  brain 
tumors  it  is  generally  clear  and  colorless.  In  hemorrhage  into  the  ven- 
tricles fluid  blood  may  be  obtained  by  puncture,  while  in  icterus  the  fluid  is 
yellowish.  As  a  rule  a  turbid  fluid  points  to  an  acute  meningitis.  Albumin 
may  be  present  and  the  specific  gravity  is  raised  when  acute  inflammation 
of  the  meninges  exists.  Cholin,  a  substance  which  is  derived  from  the 
destruction  of  nerve  tissue,  is  present  in  the  spinal  fluid  in  cases  of  organic 
disease  of  the  nervous  system,  notably  in  paresis,  tabes  dorsalis,  syphilitic 
epilepsy,  dementia  paralytica,  cerebral  abscess,  brain  syphilis,  myelitis, 
and  spina  bifida. 

Bacteriological  studies  of  the  spinal  fluid  are  most  essential  in  diag- 
nosis. The  following  are  the  more  important  bacteria  which  have  been 
found  by  lumbar  puncture:  meningococcus,  pneumococcus,  staphylo- 
coccus, streptococcus,  B.  tuberculosis,  B.  coli  communis,  B.  influenzae,  B. 
mallei,  B.  pyogenes  fcetidus. 

Trypanosomes  are  present  in  the  spinal  fluid  in  African  sleeping 
sickness. 

Cytological  Examination. — The  results  of  cytological  studies  of  the 
cerebrospinal  fluid  fall  in  line  with  those  previously  mentioned.  In  tuber- 
culosis a  high  lymphocyte  count  is  the  rule.  Lymphocyte  preponderance 
has  also  been  noted  in  paresis,  tabes,  cerebrospinal  syphilis,  syringomyelia, 
cerebral  tumors,  pressure  myelitis,  in  chronic  and  in  later  stages  of  cere- 
brospinal meningitis,  in  epilepsy,  and  in  sleeping  sickness.  In  acute 
meningitis,  such  as  is  determined  by  the  meningococcus,  staphylococcus, 
streptococcus,  pneumococcus,  B.  typhosus,  B.  coli  communis,  a  multi- 
nuclear  cellular  predominance  exists. 

Contents  of  Cysts. — Pancreatic  Cysts. — The  evidence  that  the  fluid 
from  an  abdominal  cyst  has  the  property  of  digesting  albumin  in  an 
alkaline  medium  suggests  a  pancreatic  origin.  A  negative  resull  does  not 
rule  out  the  possibility  of  pancreatic  cyst ,  since  t  r\  psin  disappears  in  collec- 
tions of  long  Btanding. 

Ovarian  Cyst. — Fluid  of  ovarian  cysts  is  often  pale  yellow,  sometimes 


320  MEDICAL  DIAGNOSIS. 

reddish  or  dark  brown;  the  specific  gravity  shows  wide  fluctuation  between 
1.010  to  1.038;  the  consistency  varies  from  a  watery  fluid  to  dense,  viscid, 
"jelly-like"  material. 

Cystic  collections  of  low  specific  gravity  contain  little  albumin  (serum 
albumin  and  globulin),  while  those  of  high  specific  gravity  have  large 
amounts  of  albumin.  Mucin  is  present  in  colloid  cysts.  Pseudomucin 
or  metalbumin  also  exists  in  these  cysts. 

Ciliated  cylindrical  epithelial  cells,  squamous  epithelium,  erythrocytes, 
fat,  fatty  acid  crystals,  choiesterin  plates,  and  haematoidin  are  also  noted 
in  the  cysts. 

Hydatid  Cysts. --They  may  be  recognized  by  the  presence  of  cyst 
membrane,  scolices,  and  hooklets.  The  fluid  of  these  cysts  is  almost  color- 
less, of  very  low  specific  gravity,  contains  little  or  no  albumin,  shows  a 
considerable  amount  of  sodium  chloride,  has  a  neutral  or  faintly  acid  reac- 
tion, and  traces  of  sugar  and  succinic  acid  may  be  present.  Granular  and 
fatty  detritus,  calcareous  fragments,  hsematoidin,  choiesterin  crystals,  and 
granular  cells  are  frequently  found.  In  the  event  of  suppuration  leuco- 
cytes appear  in  the  fluid. 

Hydronephrosis. — The  fluid  of  hydronephrosis  does  not  always  pre- 
sent features  which  are  diagnostic.  This  applies  especially  to  chronic 
hydronephrosis  with  complete  occlusion  of  the  ureter.  In  acute  cases 
or  those  associated  with  partial  occlusion  of  the  ureter  so  that  the  kidney 
still  functionates,  the  presence  of  a  high  urea  content  and  uric  acid, 
and  especially  when  renal  tube-casts  and  cells  are  found,  renders  the 
diagnosis  a  comparatively  simple  matter. 


IX. 
THE  EXAMINATION  OF  THE  NERVOUS  SYSTEM. 

PRELIMINARY   CONSIDERATIONS. 

The  diagnosis  of  disease  of  the  nervous  system  demands  an  accurate 
knowledge  of  the  anatomy  and  physiology  of  the  structures  involved  and 
of  the  pathological  processes  to-  which  they  are  liable.  It  is  essential 
to  determine  not  only  the  location  but  also  when  possible  the  nature 
of  the  lesion. 

The  nervous  system,  by  which  the  organism  is  brought  into  relation 
with  its  environment  and  by  which  its  functions  are  made  manifest  and 
controlled,  is  essentially  composed  of  morphological  units  having  a  similar 
structure — the  neurons — and  held  together  and  supported  by  a  special 
tissue — the  neuroglia. 

The  Neuron.  —  Each  neuron  consists  of  (a)  a  nucleated  proto- 
plasmic mass — the  cell-body — which  presides  over  the  nutrition  of  the  neu- 
ron and  is  the  seat  of  origin  of  nervous  impulse,  and  (b)  processes  which 
form  outgrowths  from  the  cell-body  and  constitute  the  elements  along  which 
impulses  are  conveyed.     These  processes  are  of  two  kinds,  (a)  branched 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  321 

protoplasmic  outgrowths,  dendrites,  which  may  be  multiple  and  form' 
arborescent  interlacing  ramifications  with  similar  processes  from  other 
neurons,  and  (b)  the  single  elongated  process,  axon,  commonly  prolonged 
to  form  the  axis-cylinder  process. 

The  dendrites,  uneven  in  contour  and  relatively  thick  as  they  arise 
from  the  cell-body,  rapidly  become  more  slender  in  consequence  of  their 
repeated  branching  until  they  terminate  in  delicate  end  branches  with 
terminal  bead-like  thickenings. 

The  axons  are  slender  thread-like  extensions  of  uniform  diameter 
and  variable  length,  sometimes  reaching  onty  to  adjacent  neurons,  some- 
times extending  to  distant  neurons  within  the  cerebrospinal  axis,  as  from 
the  cerebral  cortex  to  the  lower  part  of  the  spinal  cord,  sometimes  beyond 
as  from  the  lower  part  of  the  cord  to  the  muscles  of  the  foot.  The  axons, 
like  the  dendrites,  finally  terminate  in  end  arborizations — telodendria. 
Most  of  them,  shortly  after  leaving  the  cell-body,  give  off  processes  termed 
collaterals  which  after  a  variable  course  terminate  in  end  arborizations 
which  interlace  with  the  processes  of  other  and  sometimes  distant  neurons. 
Less  frequently  short  axons  arise  which  are  not  continued  as  axis-cylinders 
but  at  once  terminate  in  complex  branching  end  brushes  within  the  sub- 
stance of  the  gray  matter. 

Histologists  are  not  of  accord  as  to  whether  the  relation  between 
the  neurons  is  that  of  continuity  or  simple  contiguity.  The  weight  of 
opinion  is  at  present  in  favor  of  the  view  that  the  neurons  are  separate 
and  distinct  morphological  units,  their  processes  interlaced  to  form  paths 
of  conduction  but  probably  never  actually  continuous  in  the  anatomical 
sense.  The  axis-cylinders,  usually  supplied  with  a  medullary  sheath,  are 
described  as  nerve-fibres.  Collected  into  bundles  they  form  the  nerve- 
trunks  which  ramify  to  the  various  muscles  and  other  organs. 

Divisions  of  the  Nervous  System. — Central  Portion. — In  verte- 
brates there  is  an  axial  accumulation  of  the  cell-bodies  in  the  cerebrospinal 
axis  from  and  to  which  the  processes  pass.  This  includes  the  brain  and 
spinal  cord  and  contains  the  principal  axial  collections  of  neurons. 

Peripheral  Portion. — This  division  embraces  the  nerve-cells  of  the 
sensory  ganglia  and  is  chiefly  made  up  of  the  nerve-fibres  which  pass  to 
and  from  the  end  organs. 

Sympathetic  Nervous  System. — This  division  is  intimately  correlated 
with  the  peripheral  nervous  system,  but  possesses  a  certain  degree  of 
physiological  independence  and  supplies  the  unstriped  muscular  and  the 
glandular  tissues  of  the  body  and  the  muscle  of  the  heart. 

Nerve  Terminations. — The  terminal  end  arborizations  of  the  pe- 
ripheral nerves  constitute  the  mechanism  by  which  the  various  structures 
of  the  body  are  combined  in  consistent  and  harmonious  relation  with  the 
nervous  system.  Certain  of  these  terminations  transmit  impulses  which 
give  rise  to  muscular  contraction;  others  originate  impulses  which  cause 
various  sensations  of  pain,  temperature,  pressure,  or  the  special  senses. 
The  nerve  terminations  may  therefore  be  divided  according  to  their  func- 
tion into  motor  and  sensory. 

Motor  Nerve  Endings. — These  include  three  groups:     (a)  The  terminal 

arborization  of  the  axons  of  neurons  in  the  motor  nuclei  of  the  spina'  cord 
21 


322 


MEDICAL  DIAGNOSIS. 


and  brain  stem  that  pass  to  voluntary  muscle;  (b)  those  of  sympathetic 
neurons  that  pass  to  involuntary  muscle;  (c)  the  muscle  of  the  heart. 
Sensory  Nerve  Endings. — These  are  the  peripheral  terminal  arboriza- 
tions of  the  neurons,  the  cell-bodies  of  which  are  in  the  spinal  and  other 
sensory  ganglia.  They  therefore  constitute  the  point  of  departure  of  the 
paths  which  conduct  sensory  stimuli  to  the  central  nervous  system. 

The  function  of  the  neuron  is  to  conduct  nervous  impulses.  In  its 
simplest  form  the  nervous  system  consists  of  (a)  the  sensory  neuron, 
which  receives  the  external  stimulus  acting  upon  the  integument  and 
other  sensory  surfaces  and  by  means  of  its  process  conducts  it  from  the 
periphery  to  the  cell-body  which  commonly  lies  in  the  cerebrospinal  axis. 
Such  a  process  constitutes  functionally  a  centripetal  or  afferent  fibre. 
The  stimulus  thus  received  is  transmitted  from  the  cell-body  of  the  sensory 

neuron  by  means  of  its  dendrites  which  inter- 
lace with  those  of  the  associated  cell-body  of 
(b)  a  motor  neuron  to  the  latter,  in  which  a 
responsive  impulse  originates  and  is  conveyed 
along  its  axis-cylinder  process — nerve-fibre — 
to  the  muscle-cell  and  causes  contraction. 
The  latter  process  is  therefore  known  as  a 
centrifugal  or  efferent  fibre.  This  elementary 
conception  of  the  relation  and  functions  of 
the  sensory  and  motor  neurons  is  greatly 
modified  by  the  fact  that  the  centripetal 
impulses  are  conveyed  to  the  cell-bodies  of 
other  neurons  not  only  in  the  immediate 
neighborhood  but  also  at  different  and  even 
distant  levels.  Neurons  of  the  same  function 
are  usually  grouped  together,  aggregations  of 
cell-bodies  forming  nuclei,  and  collections  of  the  fibres  forming  bundles, 
tracts,  or  systems.  The  former  are  situated  in  the  gray  matter  of  the 
brain  and  spinal  cord,  the  latter  run  in  the  white  substance  of  the  brain 
and  spinal  cord  and  in  the  peripheral  nerves.  By  this  means  the  various 
parts  of  the  central  nervous  system  are  connected  with  each  other  and 
with  the  muscles  and  viscera. 

Many  of  the  tracts  are  highly  complicated  and  obscure  both  as  to  their 
course  and  formation.  Others  are  simpler  and,  as  the  result  of  studies  of 
the  degenerations  caused  by  injury  or  disease,  have  been  traced  in  their 
course  through  the  cerebrospinal  axis.  Chief  among  the  latter  group  is 
the  pyramidal  tract  which  transmits  motor  impulses  from  the  cortex  to 
the  periphery. 

The  Motor  System. — A  muscular  movement  depends  upon  the  com- 
bined functional  activity  of  many  associated  neurons.  It  follows  that  the 
movements  of  the  various  parts  of  the  body  are  represented  in  the  central 
nervous  system  by  localized  aggregations  of  correlated  neurons,  or  centres. 
Muscular  movements  are  not  only  localized  in  the  motor  areas  of  the 
cerebral  cortex  but  they  are  also  localized  in  the  different  levels  of  the 
ventral  horns  of  the  spinal  cord  and  the  motor  nuclei  of  the  cerebral 
nerves.     Voluntary  motor  impulses  originating  in  the  cortex  of  the  brain 


Fig.  125. — Diagram  showing  fun- 
damental units  of  nervous  system.  A, 
sensory  neuron,  conducting  afferent 
impulses  by  its  process  (a)  from  pe- 
riphery (S);  B,  motor  neuron  sending 
efferent  impulses  by  its  process  (e)  to 
muscle. — Piersol. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


323 


pass  through  at  least  two  neurons  before  they  reach  the  muscles.     For 

this  reason  the  motor  tract  is  divided  into  an  upper  and  a  lower  segment. 

The   Upper  Motor  Seg- 


ment.—  Clinical  researches 
(Hughlings    Jackson),    experi- 
mental studies  (Hitzig,  Ferrier, 
Horsley  and  others),  and  the 
studies  of  tract  myelination  at 
progressive  periods  in  the  devel- 
o  p  m  e  n  t  of  the  cerebrum  by 
Flechsig,    have   thrown    much 
light    upon    the    functions    of 
many  of  the  cortical  regions  of 
the  brain  and  the  sensory  and 
motor  tracts.     The  cell-bodies 
of    the    upper    motor    neurons 
are    arranged    in    functionally 
allied  groups   in   the   cerebral 
cortex  over  the  ascending  fron- 
tal convolution  and  extending 
deeply  into  the  fissure  of  Ro- 
lando.  In  this  region  the  move- 
ments of  the  body  are  definitely 
represented.     It  has  been  dem- 
onstrated that  motor  impulses  are  excited  by  stimu- 
lation over  these  areas  in  a  definite  order  from  above 
downward,   as  follows:   leg,  trunk,  arm,  neck,  face; 
the  areas  for  the  leg,  trunk,  and  arm  covering  the 
upper   half,  including   the   Rolandic   surface   of   the 
convolution,  and  those  for  the  head  and  face,  together 
with  those  for  the  jaws,  lips,  tongue,  and  larynx,  the 
lower  half,  likewise  the  surface  extending  into  the 
fissure.     The  centre  for  motor  speech  lies  in  the  left 
third  frontal,  Broca's,  convolution. 

The  axis-cylinder  processes  of  the  upper  motor 
neurons  pass   from   the   gray  matter   of  the   motor 
cortex  into  the  white  matter  of  the  brain  and  form 
part  of  the  extensive  converging  tract  known  as  the 
corona  radiata.    Collected  into 
a  compact  bundle — the  pyram- 
idal tract — they  pass  between 
the  basal  ganglia  in  the  internal 
capsule  occupying  the  knee  and 
the  anterior  two-thirds  of  the 
posterior  limb.     The  move- 
ments of  the  opposite  side  of  the 
body  are   represented   at   this 


LE  G 


Fig.  126. — Diagram  of  motor  path  from  right  cortex. 
Upper  segment  black;  lower  red.  A  destructive  lesion  at  1 
causes  upper  segment  paralysis  of  the  arm  of  the  opposite 
side;  at  2  upper  segment  paralysis  of  the  opposite  si<li — 
hemiplegia;  at  3  upper  segment  paralysis  of  the  face,  arm, 
.■mil  leg  <>f  the  opposite  side  and  lower  segment  paralysis  of 
the  eye  muscles  of  the  same  Bide  crossed  paralysis;  at  4 
upper  segment  paralysis  of  arm  and  leg  of  the  opposite  side 
ana  Lower  segment  paralysis  of  the  face  and  external  rectus 
of  the  -a  me  side— crossed  paralysis;  at  5  tipper  segment  paral- 
ysis of  all  muscles  liclow  lesion  and  lower  segment  paralysis  of 
muscles  represented  at  level  of  lesion — spinal  paraplegia;  at 
•  ;  lower  segment  paralysis  of  muscles  represented  at  level 
of  lesion — anterior  poliomyelitis. — YanGehuchtcn  modified. 


level   from  before  backward   in   the  following  order:    eyes,   head,   tongue, 
mouth;  shoulder,  elbow,  wrist,  fingers,  thumb;  trunk;  hip,  ankle,  knee,  toes. 


324 


MEDICAL  DIAGNOSIS. 


Emerging  from  the  internal  capsule  the  fibres  of  the  pyramidal  (cor- 
ticospinal) tract  pass  into  the  crus.    At  this  point  some  of  them  leave  the 


Fig.  127. — Diagram  of  cortical  centres. 


tract  and  crossing  the  middle  line  end  in  arborizations  among  the  ganglion 
cells  in  the  nucleus  of  the  third  nerve  upon  the  opposite  side,  and  at  succes- 
sive levels  fibres  are  given  off  which 
terminate  in  the  nuclei  of  all  the  motor 
cerebral  nerves  of  the  opposite  side, 
while  a  limited  number  of  fibres  are 
distributed  to  the  corresponding  nuclei 
of  the  same  side.  From  the  crus  the 
pyramidal  tract  enters  the  pons  and 
passes  to  the  medulla  oblongata  form- 
ing its  anterior  area — the  pyramid. 
At  the  lower  limit  of  the  medulla, 
after  the  fibres  to  the  nuclei  of  the 
cerebral  nerves  have  been  given  off, 
five  to  seven  coarse  strands  pass 
obliquely  across  the  anterior  median 
fissure,  interlacing  with  similar  strands 
from  the  opposite  side  and  thus 
constituting  the  decussation  of  the 
pyramids.  In  consequence  of  this 
arrangement  the  greater  number  of 
the  fibres  of  the  important  motor 
paths  pass  to  the  opposite  sides  to  reach  the  lateral  columns  of  the  cord  in 
which  they  descend  as  the  lateral  or  crossed  pyramidal  tracts.  The  fibres 
that  remain  upon  the  same  side  as  the  pyramid  from  which  they  emerge 


Fig.  128. — Diagram  of  internal  capsule  showing 
motor  and  sensory  paths. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


325 


are  collected  in  its  lateral  portion  and  descend  in  the  ventral  columns  as 
the  direct  pyramidal  tracts  or  Tiirck's  columns.  At  every  level  of  the 
spinal  cord  axis-cylinder  processes  emerge  from  the  crossed  pyramidal 
tract  to  enter  the  ventral  horns  and  end  in  arborizations  about  the  cell- 
bodies  of  the  lower  motor  neurons.  In  consequence  of  this  arrangement 
the  tract  diminishes  in  size  as  it  descends  in  the  cord.  In  a  somewhat 
similar  manner  the  fibres  of  the  direct  pyramidal  tract  cross  at  different 
levels  in  the  ventral  white  commissure  and  end  in  arborizations  about  cell- 
bodies  in  the  ventral  horns  on  the  opposite  side.  The  direct  pyramidal 
tract  also  diminishes  in  size  as  it  descends  and  commonly  ends  about  the 
middle  of  the  thoracic  portion  of  the  cord. 

Motor  impulses  originating  in  the  right 
cerebral  cortex  cause  muscular  contractions 
upon  the  left  side  of  the  body,  while  those 
starting  from  the  left  side  of  the  brain 
cause  contraction  of  the  muscles  upon  the 
right  side  of  the  body.  As  a  rule,  to  which 
there  are  few  exceptions,  the  motor  paths 
are  crossed  chiefly  at  the  decussation  of  the 
pyramids  and  to  a  less  extent  at  different 
levels  of  the  cord  by  fibres  given  off  from 
the  direct  pyramidal  tracts  to  the  cell- 
bodies  of  the  opposite  side.  This  crossing  in 
either  case  is  in  the  upper  motor  segment. 

The  Lower  Motor  Segment. — The 
cell-bodies  and  processes  of  the  neurons  of 
the  lower  motor  segment  lie  in  the  nuclei 
of  the  cerebral  motor  nerves  and  in  the 
various  levels  of  the  ventral  horns  of  the 
spinal  cord.  The  axis-cylinder  processes 
of  the  neurons  of  this  segment  leave  the 
spinal  cord  in  the  ventral  roots  and  pass 
in  the  peripheral  nerves  to  the  muscles  of 
the  body,  in  which  they  end  in  brush-like 
arborizations  in  the  motor  end  plates. 
These  neurons,  in  contradistinction  from 
the  neurons  of  the  upper  motor  segment,  which  are  crossed,  are  direct, 
that  is,  the  cell-bodies,  their  protoplasmic  processes,  and  the  muscles  to 
which  their  axis-cylinders  are  distributed  are  upon  the  same  side  of  the  body. 

The  Segments  of  the  Spinal  Cord. — The  spinal  nerves  are  con- 
nected with  the  lateral  surfaces  of  the  cord  by  fan-shaped  bundles  of  an- 
terior and  posterior  roots  which  are  collected  into  compact  strands  as  they 
are  assembled  to  form  a  common  trunk.  That  portion  of  the  cord  to  which 
the  root  fibres  of  a  spinal  nerve  are  attached  constitutes  its  cord  segment, 
the  limits  of  which  correspond  to  the  interval  which  separates  the  extreme 
fibres  of  the  nerve  and  those  of  the  adjacent  nerves.  The  spinal  cord  is 
thus  seen  to  consist  of  a  series  of  segments,  each  of  which  gives  origin  to 
the  anterior  or  motor  and  receives  the  posterior  or  sensory  root  fibres  of 
one  pair  of  spinal  nerves.     These  nerves,  commonly  numbering  thirty-one 


Fig.  129. — Diagram  of  motor  path, 
showing  the  crossing  of  the  path  in  the 
upper  segment. 


326 


MEDICAL  DIAGNOSIS. 


First  cervical „ 

vertebra         til/ 


First  thoracic 
vertebra 


First  thoracic 
spine 


First  lumbar 
spine 


Sacrum 


Coccyx  ■ 


Fig.  130. — Diagram  showing  relations  of  bodies 
and  spines  of  vertebra?  to  levels  at  which  spinal  nerves 
escape  from  vertebral  canal. — Piersol. 


pairs,  are  eight  cervical,  twelve 
thoracic,  five  lumbar,  five  sacral, 
and  one  coccygeal.  In  the  cervi- 
cal region  all  the  nerve-roots  but 
the  eighth  emerge  above  the  ver- 
tebra, while  throughout  the 
thoracic,  lumbar,  and  sacral  re- 
gions the  roots  for  each  segment 
of  the  cord  leave  the  spinal  canal 
below  the  vertebra  of  correspond- 
ing number.  Owing  to  the  fact 
that  the  vertebral  column  in- 
creases in  length  to  a  greater 
extent  than  the  cord,  there  is 
a  progressive  disparity  from 
above  downwards  between  the 
cord  segments  and  their  respec- 
tive vertebra?.  In  point  of  fact 
the  segment  corresponds  to  the 
nerve  which  is  connected  with 
it,  and  not  to  the  level  of  the 
vertebra  opposite  to  it.  The 
position  of  a  lesion  involving  a 
particular  spinal  segment  is 
therefore,  except  in  the  upper 
cervical  region,  some  distance 
above  the  vertebra  of  corre- 
sponding number.  Ziehen  has 
formulated  the  following  rule 
to  determine  the  levels  of  origin 
of  the  cervical  and  thoracic 
nerve-roots:  For  the  cervical 
nerves  subtract  one  from  the 
number  of  the  nerve,  and  the 
remainder  will  indicate  the  corre- 
sponding spinous  process;  for  the 
upper  thoracic  nerves  (I-V)  sub- 
tract two;  for  the  lower  thoracic 
nerves  (V-XII)  subtract  three. 
Axis-cylinder  processes  from  more 
than  one  segment  of  the  cord 
may  enter  into  the  formation  of 
a  peripheral  nerve  and  the  greater 
number  of  the  long  striped  mus- 
cles are  supplied  with  nerve-fibres 
from  more  than  one  segment. 

The  cutaneous  distribution 
of  the  peripheral  nerves  has 
been  accurately  worked  out  and 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


327 


is  of  diagnostic  value  in  lesions  of  the  main  trunks  and  their  ramifi- 
cations. The  segmental  areas  which  correspond  to  the  dorsal  roots, 
though  less  definitely  determined,  are  sufficiently  known  to  be  of  great 
service  in  the  segmental  localization  of  lesions  of  the  dorsal  roots  and 
the  cord.     These   skin-fields   or   dermatomes    have  been  mapped  out  as 

Thb  Localization  of  the  Functions  in  the  Segments  of  the  Spinal  Cord. 
Based  upon  the  studies  of  Starr,  Edinger,  Wuhmann,  and  others. 


Segment. 


I,  II,  and  III 
Cervical 

IV  Cervical . . 

V  Cervical  . . . 

VI  Cervical  . . 

VII Cervical. . 

VIII  Cervical 

I  Thoracic  . . . 

II  to  XII  Tho- 
racic 

I  Lumbar 

II  Lumbar  . . . 

III  Lumbar  . . 

IV  Lumbar  . . 

V  Lumbar  . . . 

I  to  II  Sacral. 
Ill  to  V  Sacral 


Reflex. 


Splenius  capitis,  trapezius,  hyoid  muscles,  diaphragm  (C  Ill— 
V),  sternomastoid,  levator  "scapulae  (C  III-V) 

Trapezius,  scaleni  (C  IV-T.  I),  rhomboid,  diaphragm,  teres 
minor,  levator  scapulae,  supraspinatus 

Diaphragm,  rhomboid,  biceps,  supinator  brevis  (C  V-VII), 
teres  minor,  subscapularis,  brachialis  anticus,  pectoralis 
(clavicular part),  supra-  and  infraspinatus  (C  V-VI),  deltoid, 
supinator  longus  (C  V-VII ),  serratus  magnus 

Teres  minor  and  major,  biceps,  supinator  brevis,  coraco-brach- 
ialis,  extensors  of  wrist  (C.  VI-VIII ),  infraspinatus,  b  achialLs 
anticus,  pectoralis  (clavicular  part),  pronator  teres,  deltoid, 
supinator  longus,  serratus  magnus  (C.  Y-VIII),  triceps  (outer 
and  long  heads) 

Teres  major,  pectoralis  major  (costal  part),  pronators  of  wrist, 
flexors  of  wrist,  subscapularis.  pectoralis  minor,  triceps,  latis- 
simus  dorsi  (C.  Vl-VIII),  deltoid  (posterior  part),  serratus 
magnus,  extensors  of  wrist  and  ringers 

Pectoralis  major  (costal  part),  latissimus,  pronator  quadratus, 
radial  lumbricales  and  interossei,  flexors  of  wrist  and  ringers 

Lumbricales  and  interossei,  thenar  and  hvpothenar  eminences 
(C.  VII-T.  I) 

Muscles  of  back  and  abdomen,  rectus  abdominis  (T.  V-T.  XII ). 
transversalis  (T.  VII-L.  I),  erectores  spina?  (T.  I-L.  V),  ex- 
ternal oblique  (T.  V-XII),  intercostals  (T.  I-T.  XII),  internal 
oblique  (T.  VII-L.  I) 

Lower  part  of  external  and  internal  oblique  and  transversalis, 
psoas  major  and  minor  (?),  quadratus  lumborum  (L.  l-II), 
cremaster 

Psoas  major  and  minor,  sartorius  (lower  part),  iliacus,  flexors 
of  knee  ( Remak) ,  pectineus,  adductor  longus  and  brevis 

Sartorius  (lower  part),  inner  rotators  of  thigh,  adductors  of 
thigh,  abductors  of  thigh,  quadriceps  i'emoris  (L.  II-L.  IV) 


Diaphragmatic. 

Dilatation  of  the  pupil  (C. 
I  V-VII). 

Scapular  (C.  V-T.  I),  supi- 
nator longus  (C.  V),  and 
biceps  (C.  V-VI). 

Triceps  and  posterior  wrist 
(C.  VI-VIII). 


Scapulohumeral    and  ante- 
rior wrist  (C.  VII-VI1I). 


Palmar  (C.  VII-T.  I). 


Epigastric  (T.  IV- VII),  ab- 
dominal (T.  VII-XII). 

Cremasteric  (L.  I— III). 


Patellar  tendon  (L.I I-IV). 
Gluteal  (L.  IV-V). 


Flexors  of  knee  (Ferrier),  abductors  of  thigh,  quadriceps 
femoris,  extensors  of  ankle  (tibialis  anticus),  adductors  of 
thigh,  glutei  (medius  and  minor) 

Flexors  of  knee  (hamstring  muscles)  (L.  IV-S.  II),  flexors 
of  ankle  (gastrocnemius  and  soleus)  (L.  IV-S.  II),  outward 
rotators  of  thigh,  extensors  of  toes  (L.  IV-S.  I),  glutei, 
peronaei 

Flexors  of  ankle  (L.  V-S.  II),  intrinsic  muscles  of  foot,  long 
Bexoi  of  toes  (L.  V-S.  II),  j)erona.'i 

Perineal  muscles,  levator  and  sphincter  ani  (S.  I-III) Vesical  (L.  IV-V)  and  anal 

(S.  I-III). 


Foot  reflex  (S.  I-II),  plantar 
(S.  II-III). 


the  result  of  observations  by  Henry  Head  in  the  distribution  of  the 
cutaneous  lesions  of  herpes  zoster  and  the  areas  of  referred  pain  and  tender- 
ness corresponding  to  certain  visceral  lesions,  and  in  cases  of  gross  lesions 
of  the  cord  by  Starr,  Kocher  and  others;  as  the  result  of  studies  of  anaes- 
thesia under  similar  conditions;  and  of  morphological  investigations,  ana- 
tomical dissections,  and  experimental  physiological  researches.  The  skin 
areas  upon  the  trunk  form  irregularly  parallel  zones,  some whal  horizontal 
in  the  erect  posture,  and  even  more  irregularly  distributed  elongated  tracts 


328 


MEDICAL  DIAGNOSIS. 


Cn 


Ci  Or1 


Cur) 


,Cbt 


Cn 


C7 


\m 


kCmi 


Li 


upon  the  extremities.  The  technic  consists  in  the  use  of  a  blunt  instru- 
ment, as  the  head  of  an  ordinary  toilet  pin,  in  determining  the  presence  of 
areas  of  abnormal  sensation  and  denning  their  boundaries. 

The  Sensory  System. — The 
path  for  sensory  conduction  is 
much  more  complicated  than 
that  for  motor  conduction  and 
is  composed  of  three  or  more 
associated  neurons,  one  above 
the  other.  The  cell-bodies  of 
the  lowest  neurons  are  situated 
in  the  ganglia  of  the  sensory 
cerebral  nerves  and  the  ganglia 
of  the  dorsal  roots  of  the  spinal 
nerves.  The  latter  ganglia  cells 
have  a  single  process  which,  after 
leaving  the  cell-body,  undergoes 
a  T-shaped  division,  one  portion 
being  the  peripherally  directed 
process  or  dendrite  (sensory 
nerve)  which  conducts  impulses 
from  the  integument,  mu- 
cous membranes,  muscles, 
tendons,  and  joints  of 
parts  of  the  body  with 
which  it  may  be  related; 
the  other  the  axon  or  axis- 
cy Under  process  which 
enters  the  spinal  cord  by  way  of  the 
posterior  root  fibre  and  conveys  the 
various  impulses  to  the  central  nervous 
system  to  be  transformed  into  sensations 
of  temperature,  touch,  muscle-sense,  and 
pain.  The  larger  number  of  the  sen- 
sory neurons  lie  outside  of  the  spinal 
cord.  The  portions  of  those  neurons 
within  the  cord  constitute  the  pat'-s  of 
sensory  conduction,  which  become  more 
intricate  as  the  various  tracts  approach 
the  brain.  Upon  entering  the  cord  the 
axons  of  the  sensory  neurons  of  the  first 
order  divide  into  an  ascending  and  a 
descending  branch  which  run  in  the 
dorsal  fasciculi.  The  short  descending 
branch,  after  giving  off  a  number  of 
collaterals,  terminates  in  the  gray  matter  of  the  cord.  The  ascending  branch 
is  of  variable  length.  It  may  soon  terminate  in  the  gray  matter  or  may  reach 
to  the  nuclei  of  the  medulla.  The  lower  sensory  neuron  does  not  cross  the 
middle  line.     The  cell-bodies  about  which  the  axis-cylinders  of  the  neurons 


Sm 


Le 


Lm 


\m 


Lntf 


5i 


Ml 


Fig.  131. — Anterior  and   posterior  segmental 
skin-fields. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  329 

of  the  first  order  and  their  collaterals  end  are  the  sensory  neurons  of  the 
second  order.  The  axis-cylinder  processes  of  many  of  those  cells  cross  to 
the  opposite  side  of  the  cord  and  run  in  the  ventrolateral  ascending  column 
of  Gowers  and  the  ground  bundles.  The  lemniscus  is  probably  the  principal 
sensory  tract  in  the  medulla,  pons,  and  cerebral  peduncles.  The  fibres  are 
not,  however,  continued  directly  to  the  cerebral  cortex  but  terminate  about 
cells  in  the  ventrolateral  portion  of  the  optic  thalamus,  from  which  point 
the  path  of  sensory  conduction  is  continued  by  a  higher  order  of  neurons, 
the  processes  of  which  terminate  in  the  postcentral  and  parietal  convolu- 
tions of  the  cortex.  Other  but  less  direct  sensory  paths  lie  in  series  of 
neurons  in  the  gray  matter  of  the  cord  and  in  the  direct  cerebellar  tract 
and  the  tract  of  Gowers,  and  pass  onward  through  the  cerebellum.  Some 
of  the  axis-cylinder  processes  of  the  sensory  neurons  of  the  first  order  and 
their  collaterals  terminate  in  arborizations  about  the  cell-bodies  of  the 
lower  motor  neurons  and  thus  complete  the  path  for  reflexes. 

It  is  probable  that  the  conduction  paths  for  cutaneous  sensory 
impulses  reach  the  opposite  side  soon  after  entering  the  cord,  and 
that  the  paths  for  muscular  sense  lie  upon  the  same  side  of  the  cord 
in  the  tracts  of  Goll,  crossing  by  way  of  the  axons  of  the  second  order 
in  the  medulla. 

Fibre  Tracts  of  the  White  Matter  of  the  Cord. — Of  these  there  are 
three  sets:  (1)  Those  which  enter  the  cord  from  the  periphery,  viscera, 
and  other  parts  of  the  body;  (2)  those  which  enter  it  from  the  brain;  (3) 
those  which  have  their  origin  in  the  cell-bodies  of  the  neurons  which  lie 
within  the  cord.  The  fibres  which  arise  from  the  same  group  of  nerve- 
cells  or  nucleus  have  the  same  function  and  a  similar  destination  and 
proceed  together  in  the  same  course,  thus  constituting  a  tract,  column, 
or  fasciculus.  Some  of  these  fibres  are  the  pathways  for  the  transmission 
of  impulses  from  lower  to  higher  levels,  and  the  strands  which  these  form 
constitute  ascending  tracts,  while  others  which  convey  impulses  from  above 
downward  enter  into  the  formation  of  descending  tracts.  These  tracts  are 
not  sharply  defined,  nor  do  their  boundaries  and  areas,  since  they  are  sub- 
ject to  increase  and  diminution  by  the  continual  accession  or  departure 
of  nerve-fibres,  remain  the  same  at  different  levels  of  the  cord.  In  fact 
the  borders  of  those  tracts  often  overlap.  Their  anatomical  differentiation 
has  been  accomplished  partly  by  the  study  of  degenerative  processes  caused 
by  experimental  methods — Wallerian  degeneration — and  partly  by  re- 
searches in  myelination  at  progressive  periods  of  development — embryo- 
logical  method.  Pathologically  they  are  differentiated  in  a  corresponding 
manner  by  the  degenerations  which  follow  traumatism  of  the  cord  and  the 
definite  and  constant  reaction  of  certain  tracts  to  pathogenic  influences 
as  in  tabea  and  other  diseases. 

Relation  of  Diseases  of  the  Cord  to  Lesions  of  the  Fibre  Tracts. — In 
tabes  and  Friedreich's  ataxia  the  posterior  columns  are  principally  in- 
volved; in  combined  sclerosis  the  posterior  columns  and  lateral  pyramidal 
tracts;  in  lateral  sclerosis  the  lateral  pyramidal  tracts;  in  amyotrophic 
lateral  sclerosis  the  lateral  pyramidal  tracts  and  the  anterior  horns, 
and  in  .-interior  poliomyelitis  and  progressive  muscular  atrophy  the 
anterior   horns. 


330  MEDICAL  DIAGNOSIS. 

Sensory  Areas  of  the  Cerebral  Cortex. — The  cortical  representation 
of  sensory  stimuli  is  less  definite  than  that  of  motion.  It  lies  posterior  to 
the  fissure  of  Rolando  and  is  extensively  distributed  over  the  post-central 
and  parietal  convolutions. 


Fig.  132. — Diagram  of  spinal  cord,  showing  the  relation  of  the  principal  tracts. 

I.  Goll's  or  postero-internal  column — fasciculus  graeilus.  Termination. — Fibres  end  around  neurons 
of  gray  matter  of  cord  or  in  nuclei  of  medulla.  Function  — Sensory  impulses  from  muscles,  tendons  and 
joints  of  same  side.     Degeneration  followed  by  ataxia  and  loss  of  muscle  sense. 

II.  Burdach's  or  posterolateral  column — fasciculus  cuneatus.  Termination. — Nucleus  cuneatus  in 
the  medulla;  Clark's  column.  Collaterals  to  neurons  of  posterior  horn.  The  root  fibres  passing  to  Clark's 
column  traverse  the  middle  and  median  part  of  this  tract.  Function. — Tactile  impulses  from  opposite 
side.  Various  afferent  impressions  of  muscle  sense,  heat,  cold  and  pain.  Degeneration  causes  pain,  anaes- 
thesia, ataxia,  and  loss  of  reflexes.  . 

III.  Lissauer's  tract  or  marginal  zone.  This  fasciculus  is  situated  immediately  dorsal  to  the  inner 
side  of  the  posterior  horn.  Composed  of  some  of  the  more  external  root  fibres  which  do  not  enter  Burdach[s 
column.  Fibres  of  small  size  and  short  course.  They  penetrate  the  substantia  Rolandi  and  end  in  arbori- 
zations about  its  cells  and  those  of  the  caput  cornu. 

IV.  Direct  cerebellar  tract — fasciculus  cerebellospinalis.  Termination. — Ascending  path  of  the  second 
order  conveying  impulses  from  Clark's  cells  to  the  cerebellum.  Function. — Impulses  from  viscera,  which 
probablv  influence  maintenance  of  equilibrium. 

V.  "Gowers's  tract — fasciculus  anterolateral  superficialis.  Termination. — Sensory  pathway  of  second 
order  connecting  cord  with  cerebellum  and  probably  with  cerebrum.  Fibres  are  chiefly  axons  of  neurons 
in  the  posterior  horn,  partly  upon  the  same  and  partly  upon  the  opposite  side.  Boundaries  not  well  defined. 
Function. — The  conveyance  of  sensory  impulses — tactile  pain  and  temperature — from  opposite  side  by 
way  of  the  anterior  commissure.  . 

VI.  Lateral  or  crossed  pyramidal  tract — fasciculus  cerebrospinal^  lateralis.  Termination. — Fibres 
are  axons  of  cortical  motor  neurons.  They  extend  from  superficial  gray  matter  of  cerebrum  to  various 
levels  of  cord,  undergoing  decussation  at  lower  part  of  medulla.  Function. — Conveyance  of  motor  impulses 
of  brain.  ,  ._.._.. 

VII.  Lateral  ground  bundle — fasciculus  lateralis  propnus.  Terminations. — Composition  very  com- 
plex. Long  descending  paths;  one  long  ascending  strand  and  many  short  strands  both  ascending  and 
descending.  Functions. — Both  motor  and  sensory.  Connects,  by  means  of  its  intersegmental  association 
fibres,  different  levels  of  the  cord  and  forms  a  direct  sensory  link  between  cord  and  higher  centres — medulla 
and  cerebrum. 

VIII.  Anterior  ground  bundle — fasciculus  anterior  propnus.  Constitutes  with  lateral  ground  bundle, 
with  which  it  is  continuous,  a  single  anterolateral  tract  or  fundamental  column.  Its  composition  and  func- 
tions are  the  same  as  those  of  the  lateral  ground  bundle.  _ 

IX.  Anterior  or  direct  pyramidal  tract — fasciculus  cerebrospinalis  anterior.  Termination. — Composed 
of  pyramidal  fibres  which  do  not  undergo  decussation  in  medulla  oblongata.  Made  up  of  15  to  20  per  cent, 
of  pyramidal  fibres.  Almost  all  fibres  cross  in  anterior  white  commissure  at  successive  levels  to  terminate  in 
arborizations  about  root  cells  of  anterior  horn  of  opposite  side.    Function. — Motor  tract  from  cerebral  cortex. 

X.  Gray  matter  of  the  cord,  a,  a',  anterior  horns;  emergences  of  anterior  motor  root  fibres;  b,  b', 
posterior  horns;  entrance  of  posterior  root  fibres;  c,  posterior  commissure;  d,  anterior  commissure.  Function. 
— Anterior  horns  motor;  posterior  sensory.  Cells  of  anterior  horns  trophic;  those  in  angle  of  posterior  com- 
missure probably  influence  automatic  movements  while  those  near  by  are  trophic  vasomotor,  and  secretory. 

Of  the  foregoing,  I,  II,  and  III  comprise  the  fibre  tracts  of  the  posterior  column;  IV,  V,  VI,  and  VII  the 
fibre  tracts  of  the  lateral  column,  and  VIII  and  IX  the  fibre  tracts  of  the  anterior  column  of  the  cord. 

The  Cortical  Areas  for  the  Special  Senses. — The  individual  sensory 
paths  terminate  in  circumscribed  regions  which  are  as  a  rule  widely  removed 
from  one  another.  As  mapped  out  by  myelination  these  areas  correspond 
to  regions  of  the  cortex  which  pathological  lesions  have  shown  to  be  related 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  331 

to  the  various  special  forms  of  sensation.  According  to  Flechsig  olfactory 
fibres  end  mainly  in  the  uncinate  gyrus;  visual  fibres  have  been  traced  to 
the  occipital  lobe  in  the  region  of  the  calcarine  fissure,  while  auditory  fibres 
run  to  the  temporal  lobe. 

It  is  in  accordance  with  these  observations  that  the  cuneus  and  cal- 
carine fissure  together  constitute  the  primary  or  lower  cortical  visual 
centre  in  which  are  represented  the  opposite  visual  half  fields,  while  the 
outer  surface  of  the  occipital  lobe  contains  centres  for  higher  visual  proc- 
esses in  which  the  vision  of  the  eye  of  the  opposite  side  is  represented. 
Mind  blindness  results  from  a  destructive  lesion  of  the  lateral  lobe  in  the 
left  hemisphere  if  both  occipital  lobes  are  involved.  A  lesion  of  the  cuneo- 
calcarine  cortex  results  in  lateral  homonymous  hemianopsia.  The  centre 
for  memory  of  the  meaning  of  printed  words,  letters,  figures,  and  objects 
seen  is  probably  in  the  left  angular  gyrus.  A  destructive  lesion  in  this 
area  is  attended  by  inability  to  read  or  comprehend  written  language 
although  ordinary  vision  is  not  impaired.  This  area  is  known  as  the  visual 
speech  centre.  The  auditory  centre  is  in  the  upper  temporal  convolution 
and  transverse  temporal  gyri  and  it  is  in  this  region  upon  the  left  side  that 
the  memories  of  the  meaning  of  heard  words  and  sounds  are  stored.  A 
special  centre  for  musical  memories  lies  anterior  to  the  auditory  centre. 
It  is  probable  that  the  centre  of  each  side  is  connected  with  both  auditory 
nerves.  The  olfactory  centre  probably  comprises  a  portion  of  the  base 
of  the  frontal  lobe  and  the  uncinate  gyrus.  The  gustatory  centre  has 
been  thought  to  be  in  the  anterior  portion  of  the  gyrus  fornicatus  near 
the  centre  for  smell.  Our  knowledge  in  regard  to  these  two  centres  is 
not  definite. 

The  centres  for  the  "  higher  psychical  functions"  are  generally  assumed 
to  lie  in  the  prefrontal  lobes,  particularly  upon  the  left  side.  Extensive 
unilateral  lesions  of  the  anterior,  portion  of  the  frontal  lobe  may  be  present 
without  causing  marked  symptoms  of  any  kind.  Atrophy  of  this  portion 
of  the  brain  is  often  marked  in  various  forms  of  dementia. 

Symptoms  due  to  derangements  of  the  motor  tracts  constitute  the 
most  important  group  of  localizing  phenomena.  They  are  objective  on 
the  one  hand  and  are  upon  the  other  caused  by  lesions  of  conduction  paths 
that  are  comparatively  well  understood.  Lesions  involving  the  motor 
path  are  irritative  or  destructive.  The  greater  number  of  the  lesions  of 
the  motor  cortex  are  at  the  same  time  destructive  and  irritative.  They 
destroy  the  nerve-cells  and  their  processes  in  a  particular  centre  and  by 
their  presence  and  advance  stimulate  those  of  adjacent  centres  into  morbid 
or  disordered  activity.  The  clinical  manifestation  of  a  destructive  lesion 
of  a  motor  centre  is  loss  of  function — paralysis;  that  of  an  irritative  lesion 
abnormal  muscular  contraction.  Important  differences  in  the  paralysis 
or  abnormal  contraction  are  dependent  upon  the  position  of  the  lesion  as 
regards  the  motor  segments.  These  differences  are  due  first  to  anatomical 
relations  and  second  to  secondary  degenerations. 

The  cortical  motor  centres  are  more  or  less  widely  separated  from  one 
another,  and  a  circumscribed  destructive  lesion  of  the  motor  area  may 
therefore  give  rise  to  a  limited  paralysis  involving  a  limb  or  a  group  of 
muscles  in  a  limb — cerebral   monoplegia.     As  the  axis-cylinder  processes 


332  MEDICAL  DIAGNOSIS. 

converge  to  form  the  pyramidal  tract  in  the  internal  capsule,  a  lesion  of 
limited  extent  causes  paralysis  of  most  of  the  muscles  upon  the  opposite 
side  of  the  body — hemiplegia.  A  lesion  in  the  pyramidal  tract  as  it 
descends,  giving  off  fibres  to  the  motor  nuclei  at  various  levels,  causes 
paralysis  of  the  muscles  having  their  spinal  centres  below  the  seat  of  the 
lesion.  It  follows  from  the  decussation  of  the  pyramids  that  when  the 
lesion  is  above  the  crossing  the  paralysis  is  upon  the  opposite  side  of  the 
body,  and  when  it  is  below  it,  upon  the  same  side. 

The  cell-body  and  particularly  its  nucleus  maintain  the  nutrition  of 
all  parts  of  the  neuron.  If  the  cell-body  be  destroyed  its  processes  undergo 
degeneration,  or  if  any  process  be  separated  from  its  cell-body  it  likewise 
undergoes  degenerative  changes  throughout  its  whole  extent — secondary 
degeneration.  Degeneration  of  the  axons  of  the  upper  motor  segment 
ceases,  however,  at  the  lower  motor  segment.  The  muscles  are  paralyzed 
but  do  not  undergo  degenerative  atrophy;  they  are  spastic;  their  reflexes 
are  exaggerated  and  they  do  not  show  qualitative  changes  in  their 
electrical  reactions. 

In  complete  transverse  lesion  of  the  cord — complete  spinal  para- 
plegia— the  muscles  upon  both  sides  are  paralyzed  below  the  lesion,  but 
they  are  flaccid;  the  deep  reflexes  are  abolished;  the  muscles  undergo 
rapid  atrophy  with  loss  of  faradic  excitability. 

Irritative  lesions  of  the  upper  motor  segment  involving  the  motor 
cortex  give  rise  to  the  convulsive  phenomena  known  as  cortical  or  Jack- 
sonian  epilepsy. 

Destructive  lesions  of  the  lower  motor  segment  cause  degeneration 
alike  of  the  axis-cylinder  processes  in  the  peripheral  nerves  and  of  the 
muscle-fibres  with  which  they  are  connected.  The  anatomical  distribution 
of  the  cell-bodies  of  the  segment  gives  rise  to  special  peculiarities  in  the 
distribution  of  the  paralysis  which  are  strongly  in  contrast  to  that  result- 
ing from  lesions  of  the  upper  motor  segment  and  which  have  important 
bearings  upon  the  localization  of  the  lesion.  These  cell-bodies  are  col- 
lected in  groups  or  nuclei  from  the  peduncles  of  the  brain  throughout 
the  entire  extent  of  the  spinal  cord  and  send  axis-cylinder  processes  to  all 
the  muscles  of  the  body.  Certain  groups  of  the  neurons  which  make  up 
the  lower  segment  are  therefore  widely  separated,  and  a  circumscribed 
lesion  may  result  in  paralysis  of  a  limited  number  of  muscles  or  a  group 
of  muscles  instead  of  one-half  of  the  body  as  in  upper  segment  paralysis — 
hemiplegia.  A  lesion  causing  lower  segment  paralysis  may  be  situated 
either  in  the  cord  or  in  the  peripheral  nerve.  If  in  the  cord  or  its  nerve- 
roots  the  paralyzed  muscles  are  not  supplied  by  a  single  nerve  but  are 
represented  in  adjacent  cord  segments  and  the  accompanying  sensory 
derangements  involve  the  skin  fields  related  to  those  segments;  if  on  the 
contrary  the  lesion  is  in  the  nerve,  the  paralyzed  muscles  and  the  anaes- 
thetic area  are  those  supplied  by  that  particular  nerve  and  its  branches. 
The  neurons  of  the  lower  motor  segment  maintain  not  only  the  nutrition 
of  their  axis-cylinder  processes  which  make  up  the  peripheral  nerves  but 
also  that  of  the  muscle-fibres  in  which  their  processes  terminate.  The 
degeneration  which  results  from  injury  of  the  cell-bodies  or  their  processes 
involves  the  muscles  to  which  they  are  distributed.    In  lower  motor  segment 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  333 

paralysis  the  affected  muscles  are  the  seat  of  degenerative  atrophy, 
manifest  in  diminished  tension,  abolition  of  their  reflexes  and  reaction  of 
degeneration — flaccid  paralysis. 

Irritative  lesions  of  the  lower  motor  segment  cause  fibrillary  con- 
tractions which  may  be  due  to  stimulation  either  of  the  cell-bodies  or  of 
their  axis-cylinder  process  in  the  peripheral  nerves;  or  they  may  give  rise 
to  spasmodic  contractions  when  the  lesion  affects  the  motor  nerve-roots 
as  they  emerge  from  the  cord. 

Symptoms  due  to  derangements  of  sensory  paths  are  of  far  less  local- 
izing value  than  motor  symptoms.  This  is  partly  due  to  the  greater  com- 
plexity of  the  sensory  tracts,  partly  to  less  exact  knowledge  concerning 
them.  If  sensory  symptoms  are  limited  to  the  distribution  of  a  peripheral 
nerve  it  is  evident  that  the  lesion  is  in  the  nerve-trunk  or  its  branches; 
if  restricted  to  the  fields  corresponding  to  one  or  more  spinal  segments 
the  cord  is  at  fault;  if  they  chiefly  affect  one  side  of  the  body,  the  brain. 
The  nature  of  the  sensory  phenomena  has  little  value.  Intense  pain,  for 
example,  may  be  symptomatic  of  peripheral  nerve  disease  as  in  some 
forms  of  neuritis,  or  of  a  degenerative  process  within  the  cerebrospinal 
axis  as  in  tabes. 

Irritative  lesions  cause  disordered  subjective  sensations  of  heat,  cold, 
formication,  and  the  like— the  paresthesias — and  pain  of  every  variety  as 
to  kind  and  degree. 

Destructive  lesions,  if  they  completely  interrupt  the  sensory  path, 
wholly  abolish  sensation  in  the  parts  of  the  body  involved.  A  lesion  of  a 
peripheral  sensory  neuron  in  the  course  of  the  nerve  gives  rise  to  anaes- 
thesia in  the  area  of  distribution  of  the  nerve;  a  complete  transverse  lesion 
of  the  spinal  cord  gives  rise  to  total  loss  of  sensation  of  all  parts  below  its 
level.  Destructive  lesions  of  the  central  nervous  system  do  not  however 
usually  interrupt  all  the  sensory* conduction  paths,  and  sensation  may  not 
be  wholly  abolished  even  in  extensive  disease.  Sensation  may  be  diminished 
or  lost  in  all  its  phases  as  in  complete  transverse  lesions  of  the  cord,  or  there 
may  be  dissociation  sensory  paralysis  as  in  certain  diseases  of  the  cord  in 
which  pain-sense  and  temperature-sense  are  abolished  while  tactile  sensa- 
tion remains  unimpaired,  or  in  some  lesions  of  the  cerebral  cortex  in  which 
there  may  be  a  loss  of  the  muscular  sense  and  astereognosis — the  loss  of 
the  ability  to  recognize  an  object  placed  in  the  hand — while  other  phases 
of  sensation  are  fully  preserved. 

EXAMINATION    OF   THE   PATIENT. 

The  Anamnesis. — An  accurate  history  of  the  case  is  of  the  highest 
importance  in  disease  of  the  nervous  system.  This  must  include  in 
many  cases  the  facts  relating  to  the  antecedents  of  the  patient,  which 
bear  upon  hereditary  predisposition,  as  the  occurrence  of  nervous  or 
mental  disease  in  the  parents,  children,  or  collateral  members  of  his  fam- 
ily. Peculiarities,  idiosyncrasies,  and  psychoses  are  especially  to  be 
ascertained,  often  a  matter  of  no  little  difficulty.  A  history  of  gout, 
alcoholism,  or  syphilis  in  a  parent,  when  it  can  be  obtained,  may  give 
the  key  to  the  situation. 


334  MEDICAL  DIAGNOSIS. 

The  investigation  of  the  personal  history  must  bear  upon  any  pre- 
vious serious  illness  and  its  nature,  whether  nervous  or  not,  and  especially 
whether  or  not  such  an  illness  was  of  a  similar  nature  to  that  from  which 
the  patient  is  suffering. 

It  may  be  necessary  to  follow  in  our  investigation  a  chronological 
order,  ascertaining  whether  or  not  nervous  symptoms  have  occurred  in 
infancy  and  childhood,  such  as  convulsions,  enuresis,  night  terrors.  The 
period  of  school  life  is  to  be  studied  in  obscure  cases.  The  neurasthenic 
may  have  been  bright  and  successful  at  school,  but  shy,  retiring,  and  not 
disposed  to  make  friends;  the  sufferer  from  petit  mal,  sometimes  confused 
and  forgetful;  the  hysterical  girl,  especially  at  puberty,  nervous  and  emo- 
tional. The  occupation  is  next  to  be  considered.  Is  it  one  that  involves 
continuous  monotony,  mental  strain,  extreme  responsibility?  Have  there 
been  prolonged  or  cumulative  depressing  emotions,  disappointment,  fear, 
sorrow,  or  grief?  Wounds  and  injuries,  alcoholism,  and  abnormal  sexual 
matters,  especially  syphilis,  are  of  etiological  importance  in  many  neuro- 
logical cases.  Severe  infectious  processes,  particularly  enteric  fever,  may 
have  been  the  point  of  departure  for  visceral  and  vascular  changes  which 
after  a  time  manifest  themselves  in  the  guise  of  nervous  disease.  Of  special 
importance  are  such  maladies  in  their  relation  to  postinfective  psychoses 
and  neurasthenia.  The  part  played  by  obscure  toxsemias  due  to  chronic 
gastro-intestinal  or  other  visceral  diseases  in  the  etiology  of  certain  spinal 
cord  degenerations  is  not  to  be  disregarded.  Notwithstanding  the  number 
of  points  to  be  considered  the  value  of  the  history  cannot  be  measured  by 
its  length.  On  the  contrary  it  is  most  important  to  briefly  record  only  the 
facts  which  are  pertinent  and  significant. 

Status  Praesens. — While  investigation  on  every  side  is  necessary  for 
a  full  understanding  of  many  nervous  cases,  yet  there  are  certain  special 
paths  of  approach  which  experience  has  taught  us  lead  most  directly  to  a 
diagnosis  in  the  average  case;  in  other  words  certain  distinctly  neuro- 
logical methods  of  investigation.  These  methods  may  be  grouped  according 
to  the  character  of  the  symptoms  and  signs  that  each  brings  into  view, 
the  most  important  being,  (1)  motor  and  (2)  sensory  symptoms;  (3)  cere- 
bral symptoms,  of  which,  on  account  of  comprehensive  and  special  char- 
acters, (4)  aphasia  requires  separate  consideration;  (5)  spinal  symptoms 
in  so  far  as  they  connect  segments  of  the  cord  with  particular  regions  of 
the  body;  (6)  the  reflexes;  (7)  electrical  phenomena;  (8)  trophic  disturb- 
ances;   (9)  pain  and  temperature;    (10)  muscular  sense. 

1.   Motor  Symptoms. 

Paralysis. — Motor  paralysis  signifies  impairment  of  some  portion  of 
the  motor  pathway.  When  partial  it  is  to  be  distinguished  from  akinesia, 
common  in  states  of  mental  stupor,  and  from  incoordination,  often  mis- 
taken by  the  patient  and  his  friends  for  true  weakness.  The  practical 
tests  for  muscular  weakness  consist,  for  the  hand  and  forearm,  in  estimat- 
ing the  patient's  "grip"  as  he  squeezes  the  hand  of  the  examiner,  especially 
in  comparing  the  grip  of  an  affected  hand  with  the  other,  which  may  be 
normal  or  less  affected.    Of  mechanical  devices  the  dynamometer  of  Math- 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  335 

ieu  is  most  commonly  used.  The  power  of  arms  and  legs  is  tested  by  having 
the  patient  make  various  movements  while  the  examiner,  grasping  the 
part,   offers  resistance. 

A  general  surmise  as  to  the  location  of  the  lesion  (cerebral  or  spinal) 
causing  the  impairment  of  the  motor  path  is  made  by  observing  whether 
the  affected  part  is  flaccid  or  spastic.  Flaccidity  nearly  always  denotes 
a  lesion  of  lower  motor  neurons  (ganglion  cells  of  ventral  gray  horns, 
peripheral  nerves  with  their  terminals)  as  seen  in  poliomyelitis  and  neu- 
ritis, while  spasticity  signifies  a  lesion  of  central  or  upper  motor  neurons 
(cell-bodies  of  motor  cortex,  fibre  tracts  through  subcortex,  internal  cap- 
sule, pons,  medulla,  ventral  and  lateral  pyramidal  tracts  of  spinal  cord),  as 
in  old  brain  hemorrhage. 

A  notable  exception  to  this  broad  rule  is  that  in  lesion  of  the  spinal 
cord,  complete  or  nearly  complete  transversely,  especially  one  high  up  in 
the  cord,  the  effect  is  as  if  all  motor  neurons  below  it  were  destroyed, 
i.e.,  there  is  total  flaccid  paralysis  below  the  level  of  the  lesion.  The  expla- 
nations of  this  phenomenon  are  numerous  but  unsatisfactory.  Another 
exception  to  this  rule  is  readily  correlated  with  it  by  bearing  in  mind 
that  the  superior  motor  neurons  of  the  pyramidal  tract  are  not  wholly 
cerebral  but  have  a  spinal  portion  which  is  mostly  contained  in  the 
lateral  tract;  hence  it  follows  that  a  spinal  palsy  is  spastic  if  the  lateral 
tracts  are  involved. 

To  decide  whether  a  member  be  flaccid  or  spastic,  all  the  patient's 
active  movements,  including  gait,  are  to  be  studied,  as  well  as  various 
passive  motions  which  may  suggest  themselves  to  the  examiner.  His 
opinion  will  be  rather  one  of  judgment  than  of  definite  methods. 

Monoplegia  is  a  paralysis  restricted  to  one  member,  whether  this  be 
disabled  entirely  or  only  in  one  group  of  muscles.  Hemiplegia,  or  paraly- 
sis of  one  side  of  the  body,  is  nearly  always  due  to  a  brain  lesion,  and, 
when  so,  the  upper  face  will  be  found  unaffected  or  slightly  affected, 
except  in  recent  cases  where  the  paralysis  in  the  upper  distribution  of  the 
facial  nerve  may  be  very  distinct  for  a  time.  The  slight  implication  of 
the  upper  face  is  characteristic  of  a  long-standing  cerebral  hemiplegia. 
Diplegia — double  hemiplegia — occurs  particularly  in  childhood.  Para- 
plegia is  a  symmetrical  paralysis  involving  the  upper  or  lower  limbs,  but 
when  the  term  is  used  without  qualification  it  refers  to  paralysis  of  the 
lower  limbs.  The  term  bracftial  paraplegia  is  employed  to  denote  paralysis 
of  the  upper  limbs;  crural  paraplegia  that  of  the  lower.  It  is  generally 
a  spinal  palsy. 

Contracture.  —  In  paralysis  of  long  duration  contractures  appear 
which  are  generally  characteristic.  Those  which  arise  in  spastic  paralyses 
depend  upon  shortening  of  the  paralyzed  muscles,  the  stronger  muscles 
contracting  more  than  the  weaker,  and  produce  such  postures  of  the  limbs 
as  are  seen  in  hemiplegia  (flexion  of  elbow,  wrist  and  fingers,  adduction  of 
arm  to  chest,  extension  of  the  leg  on  the  thigh,  adduction  of  the  knees, 
extension  of  the  foot  and  inversion  with  plantar  flexion  of  toes).  According 
to  some  investigators  the  contractures  of  cerebral  hemiplegia  are  the  result 
of  the  greater  paralysis  in  certain  groups  of  muscles.  The  contractures 
in  flaccid  paralyses  depend  upon  the  unbalanced  action  of  the  opposing 


336  MEDICAL  DIAGNOSIS. 

sound  muscles,  as  seen  in  the  aceeentuated  wrist-drop  and  foot-drop  of  old 
peripheral  neuritis,  or  depend  upon  the  contraction  of  the  paralyzed 
muscles  themselves. 

Convulsions  and  spasm    (see  Part  III,  p.  604). 

Jacksonian  epilepsy    (seep.  605). 

Athetosis  or  mobile  spasm  consists  of  irregular  writhing  movements, 
especially  of  the  fingers  but  also  of  the  arms  and  other  parts.  It  is  almost 
pathognomonic  of  the  cerebral  palsies  of  childhood,  in  which  affections  the 
symptom  may  mislead  by  being  more  prominent  than  the  hemiplegia  or 
diplegia  which  underlies  it.  Occurring  in  adult  hemiplegias  these  movements 
are  sometimes  called  posthemiplegic  chorea,  but  are  less  prominent  than  the 
weakness  and  rigidity  of  the  limb.  Athetosis  is  usually  aggravated  by  volun- 
tary movements,  as  when  the  patient  attempts  to  pick  up  a  small  object. 
'  Tremor    (see  p.  608). 

Fibrillary  tremor  or  fibrillary  twitching   (see  p.  609). 

Tics. — Twitching  simultaneous  over  a  large  area,  inducing  a  purposive 
movement  at  intervals  and  habitually,  is  called  a  "tic."  It  is  not  a  sign 
of  any  known  lesion  but  is  functional  (a  neurosis). 

Ataxia. — In  the  course  of  investigation  of  motor  signs  the  examiner  may 
observe  irregularity  and  uncertainty  in  various  acts  which  require  a  degree 
of  precision.  Ataxia  results  from  inharmonious  action  of  muscle-groups 
even  when  disorder  of  motility,  either  excess  or  deficiency,  is  not  present. 

The  defect  is  largely  in  the  muscular  sense,  which  is  discussed  in  its 
relation  to  astereognosis.  Yet  the  practical  tests  for  the  symptom  are 
motor.  In  the  arm  ataxia  is  discovered  by  directing  the  patient  to  close 
his  eyes  and  then  with  his  index  finger  to  touch  the  tip  of  his  nose,  or  to 
meet  the  tip  of  the  other  index  finger  in  sweeping  the  arms  around  hori- 
zontally in  front;  in  the  leg,  by  having  him  attempt  to  touch  one  knee 
with  the  heel  of  the  other  foot.  If  there  be  considerable  ataxia  the  patient 
touches  wide  of  the  mark.  Ataxia  of  the  legs  is  better  revealed  in  the 
patient's  manner  of  walking,  which  is  considered  in  connection  with  other 
disorders  of  gait. 

2.   Sensory  Symptoms. 

Studies  of  sensation  involve  a  subjective  element  which  makes  them 
at  best  uncertain.  Scientific  methods  aim  to  diminish  this  uncertainty 
by  magnifying  the  objective  element  through  the  use  of  technical  pro- 
cedures which  render  the  examiner  less  dependent  upon  the  patient's 
statements.  In  children,  and  in  stuporous  and  demented  patients,  the 
objective  element  alone  is  considered — a  start,  a  vocal  sound,  or  the  with- 
drawal of  a  member  when  the  patient  is  touched,  pricked,  etc. 

Paresthesia. — "  Numbness  and  tingling,"  "  pins  and  needles,"  "crawl- 
ing sensations" — formication — and  burning  sensations  are  symptoms  of 
sensory  irritation.  They  are  prominent  in  neuritis,  and  in  spinal  diseases 
which  implicate  the  posterior  nerve-roots  (see  also  p.  598). 

Delayed  Sensation. — Recognition  of  any  artificial  sensation  is,  for 
the  purposes  of  the  clinician,  instantaneous;  if  an  interval  occurs  between 
the  application  of  a  stimulus  and  the  patient's  response  to  it,  we  speak  of 
"delayed  sensation,"  which  is  common  especially  in  tabes  dorsalis. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  337 

Pain. — Pain  is  a  prominent  symptom  of  many  nervous  diseases. 

The  objective  study  of  sensation  comprises  the  testing  of  the  senses  of 
touch — common  sensibility — of  pain,  and  of  temperature.  The  muscular 
sense  is  of  interest  clinically  in  relation  to  astereognosis,  and  also  in  relation 
to  ataxia  of  movement,  which  may  arise  from  defect  of  the  muscular  sense. 

In  testing  the  sense  of  touch  it  is  well  to  blindfold  the  patient,  to  take 
care  that  the  surface  examined  shall  not  be  chilled  by  exposure,  and  to 
touch  the  part  with  light  pressure  and  without  causing  pain.  The  instru- 
ment most  commonly  used  for  this  purpose  is  Carroll's  aesthesiometer, 
but  a  tooth-pick  or  a  feather  will  serve.  The  patient  is  directed  to  say 
"now"  when  the  touch  is  felt;  or  to  count  successive  touches  a  short 
distance  apart,  ''one,  two,  three,"  etc.,  and  the  failure  to  note  one  or  more 
touches  will  mark  the  boundary  of  an  area  of  anaesthesia.  Sensibility  to 
touch  is  more  acute  on  the  back  than  on  the  front  of  the  body.  Loss  of 
tactile  sensibility,  either  total — ancesthesia — or  partial — hypcvsthesia — may 
be  functional  and  a  sign  of  hysteria,  in  which  case  it  commonly  affects 
half  the  body — hysterical  hemianesthesia — or  a  segment  of  one  limb,  or 
all  of  one  extremity  up  to  a  certain  level — "glove-anaesthesia"  and  "stock- 
ing-anaesthesia;" or  anaesthesia  and  hypaesthesia  may  constitute  a  sign  of 
organic  nervous  disease  which  is  destructive  in  character  or  is  at  an  ad- 
vanced stage.  In  the  case  of  hemi hypaesthesia  or  hemianaesthesia,  the 
hemorrhage  or  other  destructive  lesion  may  be  in  the  posterior  part  of  the 
internal  capsule — where  according  to  some  anatomists  sensory  fibres  are 
collected  into  a  bundle  (carrefour  sensitif) — in  the  tegmentum  of  the  pons, 
or  in  the  spinal  cord,  provided  one  lateral  half  of  the  pons  or  cord  be  severed. 
In  any  of  the  cases  mentioned  the  lesion  is  situated  on  the  side  opposite  to 
that  of  the  anaesthesia. 

In  testing  the  pain  sense,  a  needle-point  or  one  of  the  sharp  points 
of  the  aesthesiometer  is  employed,  and  the  skin  is  "pricked,"  not  scored, 
with  the  instrument.  Remind  the  patient  that  actual  pain,  not  the  mere 
sense  of  being  touched,  is  to  call  forth  his  response;  or  instruct  him  to  say 
"touch,"  or  "  pain,"  according  as  the  one  or  the  other  sensation  is  excited 
by  the  sharp  point. 

The  temperature  sense  is  well  studied  by  the  use  of  two  test-tubes  of 
water,  one  heated  to  about  100°  F.  or  above,  the  other  cooled  to  60°  F.  or 
lower,  the  tubes  being  applied  alternately,  and  each  being  held  in  contact 
with  the  skin-surface  for  several  moments,  since  recognition  of  heat  or  of 
cold  is  commonly  less  prompt  than  that  of  touch  and  of  pain.  The  heat 
of  the  one  tube  should  not  be  sufficient  to  burn,  as  that  would  introduce 
the  factor  of  pain;  yet  practically  this  distinction  is  of  little  consequence, 
because  the  thermic  sense  and  the  pain  sense,  being  conducted  in  adjacent 
tracts  of  the  cord,  are  commonly  abolished  together.  Ordinarily  when 
tactile  anaesthesia  has  been  demonstrated  in  a  certain  area,  we  may  expect 
to  find  thermo-anaesthesia  and  analgesia  associated  with  it.  But  the  con- 
verse of  this  does  not  always  hold  true;  for  over  surfaces  which  betray  no 
tactile  anaesthesia,  or  al  most  only  hypaesthesia,  we  may  find  areas  of  anal- 
gesia and  thermo-anaesthesia.  This  is  that  dissociated  sensory  loss  which 
is  niosi  common  in  syringomyelia,  though  other  lesions  of  the  central  part. 

of  the  gray  matter  of  the  cord  may  cause  the  phei tenon. 

22 


338  MEDICAL  DIAGNOSIS. 

3.   Regional   Diagnosis   of  Cerebral   Disease. 

General  Symptoms. — The  general  symptoms  of  intracranial  disease — 
vomiting,  headache,  and  optic  neuritis — have  little  value  in  cerebral  locali- 
zation. Headache  is  more  likely  to  be  frontal  in  lesions  of  the  fore-brain 
and  occipital  in  those  in  or  about  the  cerebellum,  but  this  is  not  constant. 
Dense  tumors  of  some  size,  well  above  the  base  of  the  skull,  may  yield  a 
shadow  on  the  X-ray  plate. 

Predominant  mental  symptoms  are  suggestive  of  lesion  of  the  pre- 
frontal lobes,  particularly  the  left;  but  it  must  be  remembered  that  after 
head  injuries  delirium,  confusion,  or  stupor  may  ensue  from  shock,  with- 
out reference  to  severity  or  site  of  the  trauma,  and  moreover  that  demon- 
strable brain  lesions  are  comparatively  rare  causes  of  insanity. 

Paralysis. — Of  motor  signs  indicating  lesion  of  the  precentral  con- 
volution, anterior  to  the  fissure  of  Rolando,  paralysis  has  the  greatest 
localizing  value.  Paralyses  in  the  distribution  of  cranial  nerves,  especially 
of  several,  commonly  indicate  lesion  at  the  base  of  the  brain.  If  a  single 
cranial  nerve  is  implicated,  the  lesion  is  probably  outside  of  the  central 
nervous  system;  if  one  arm  or  leg  is  paralyzed,  a  cortical  lesion  should  be 
suspected,  and  this  is  rendered  probable  if  the  paralyzed  part  is  the  seat 
of  clonic  spasm.  Paralysis  of  the  face  indicates  lesion  in  the  lower  third  of 
the  Rolandic  cortex;  paralysis  of  an  arm  or  leg,  lesion  of  the  middle  or 
upper  third  respectively. 

Astereognosis. — Pure  motor  phenomena  point  to  a  lesion  anterior  to 
the  fissure  of  Rolando;  if  the  lesion  be  posterior  to  this  fissure  (postcentral) 
the  motor  signs  are  likely  to  be  associated  with  the  phenomenon  called 
astereognosis,  which  becomes  more  prominent  as  the  parietal  lobe  is  en- 
croached upon.  By  study  of  the  "  stereognostic  sense"  which  is  the  physio- 
logic process  by  which  solid  objects  are  recognized  by  contact,  neurologic 
diagnosis  has  made  a  distinct  advance.  Astereognosis,  or  want  of  this 
sense,  may  be  diagnostic  of  lesion  of  the  superior  parietal  lobule.  To  test 
ior  this  phenomenon  it  is  well  to  study  separately  the  several  processes  by 
which  normally  the  hand  recognizes  the  shape  and  size  of  objects,  especially 
the  "spacing  sense,"  the  sense  of  position,  and  the  pressure  sense,  the 
last  two  of  which  are  the  chief  components  of  the  muscular  sense. 

The  "spacing  sense"  is  tested  by  touching  the  skin  at  two  points 
simultaneously,  as  with  the  two  arms  of  the  sesthesiometer,  and  observing 
how  near  together  they  may  be  while  still  recognized  as  two  points.  The 
examiner  compares  his  results  with  those  obtained  in  a  normal  subject. 

The  sense  of  position  is  studied  by  asking  the  patient  (blindfolded)  to 
tell  where  his  hand  or  foot  is,  after  the  examiner  has  quietly  placed  it  in 
a  particular  attitude,  or  to  imitate  with  one  limb  an  attitude  given  to  the 
other  by  the  examiner. 

The  pressure  sense  is  tested  by  blindfolding  the  patient,  placing  his 
hand  supine  upon  a  table,  and  laying  in  his  palm,  one  after  another, 
small  objects  identical  save  in  their  weight,  which  is  graded  in  a  series. 
For  this  purpose  cartridges  filled  with  layers  of  cotton  and  regulated 
numbers  of  buckshot  may  be  used.  The  main  test,  which  reveals 
astereognosis    directly    if   it    be    at    all    pronounced,    consists    in    handing 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  339 

the  patient  various  common  objects, — watch,  spool,  block  of  wood,  pen- 
knife,— each  of  which  he  essays  to  name  or  to  describe. 

Deafness,  in  the  absence  of  disease  of  the  external,  middle  or  internal 
ear,  may  be  due  to  lesion  of  the  first  or  second  temporal  convolution, 
particularly  that  of  the  left  side. 

Blindness  without  demonstrable  cause  in  the  eye  may  be  due  to  lesion 
anywhere  in  the  course  of  the  optic  nerves,  tracts  or  "radiations"  as  far 
as  the  cunei  lobes,  which  face  one  another  across  the  great  longitudinal 
fissure  in  the  occipital  lobe.  Unilateral  blindness  of  both  eyes  and  in  the 
same  side  of  each  eye  (lateral  homonymous  hemianopsia)  indicates  that 
the  lesion  is  unilateral,  that  it  is  back  of  the  optic  chiasm  and  is  on  the 
side  opposite  to  that  on  which  the  patient's  vision  has  failed — that  is,  on 
the  same  side  as  the  blind  half-retina.  To  determine  how  far  back  of  the 
chiasm  such  a  lesion  is  we  must  rely  on  signs  and  symptoms  arising  from 
involvement  of  contiguous  structures,  especially  (in  lesions  at  the  base  of 
the  brain)  the  cranial  nerves,  which  are  spared  in  lesion  of  the  optic  radia- 
tions, or  of  the  cuneus — subcortical  or  cortical  lesions.  A  theoretically 
positive  means  of  distinguishing  basal  from  cortical  lesions  causing  hemi- 
anopsia is  Wernicke's  pupillary-inaction  sign,  which  consists  in  the 
absence  of  the  light  reflex  of  the  iris  when  only  the  blind  half  of  the  retina 
is  illuminated.  The  finding  of  this  condition  points  to  a  basal  lesion, 
i.e.,  at  or  below  the  optic  thalamus  and  external  geniculate  body,  for  con- 
traction of  the  iris  is  a  function  of  the  third  nerve,  and  no  part  of  this 
nerve  extends  above  the  "primary  optic  centres,"  which  are  at  the  base 
of  the  brain. 

Partial  loss  of  vision t  not  accounted  for  by  eye  disease,  may  be  due 
to  lesion  of  the  angular  gyrus,  visual  acuity — macular  vision — being  im- 
paired; or  it  may  be  due  to  lesion  in  front  of  the  optic  chiasm,  in  the 
angle  between  the  optic  nerves,  where  b}^  interfering  with  the  internal 
fibres  of  each  nerve  it  causes  blindness  of  each  inner  (nasal)  half-retina,  a 
condition  called  (from  the  blind  half-fields)  temporal  hemianopsia,  which 
is  pathognomonic  of  lesion  in  the  situation  described. 

Symptoms  of  Cerebellar  Disease. — The  cerebellum  is  to  the  clinician 
chiefly  an  organ  of  coordination,  and  this  function  resides  mainly  in  the 
middle  lobe.  The  cardinal  signs  of  cerebellar  disease  are  nystaguius  and 
a  peculiar  ataxia  which  gives  a  staggering  character,  or  titubation,  to  the 
patient's  gait.  This  ataxia  disappears  when  the  patient  lies  down,  and 
the  knee-jerks  are  often  preserved.  Neoplasms  beneath  the  middle  lobe 
of  the  cerebellum  are  likely  to  cause  this  form  of  ataxia  together  with 
external  ocular  palsies  from  pressure  upon  the  nuclei  of  the  third  and  fourth 
nerves  beneath  the  quadrigeminal  bodies.  A  tumor  arising  from  these 
bodies  can  hardly  be  distinguished  from  cerebellar  tumor  implicating 
the  vermis. 

The  Internal  Capsule. — Of  the  great  interior  structures  of  the  brain 
only  the  posterior  limb  of  the  internal  capsule  has  functions  so  definite  that 
certain  symptoms  may  be  referred  to  it.  Sudden  hemiplegia,  with  hemi- 
ansesthesia  and  hemianopsia,  is  generally  indicative  of  lesion  in  the  internal 
capsule,  since  this  complex  of  symptoms  from  cortical  or  even  subcortical 
lesion   could   he  induced   <>nlv  bv   uncommonly  extensive  damage.     The 


340  MEDICAL  DIAGNOSIS. 

symptoms  referable  to  single  minute  destructive  foci  in  the  posterior  limb 
of  the  capsule,  from  the  "knee"  backwards,  are,  so  far  as  is  known,  (1) 
paralysis  of  the  face  from  above  downwards,  (2)  of  the  arm  and  (3)  of  the 
leg,  also  from  above  downwards.  (4)  anaesthesia  of  varying  extent  up  to 
hemianesthesia,  which  probably  indicates  destruction  of  the  posterior 
third  of  the  posterior  limb,   (5)  hemianopsia. 

Cerebral  Ganglia. — Of  the  great  cerebral  ganglia  none  has  an  independ- 
ent symptomatology.  Lesions  affecting  the  corpus  striatum  cause  pre- 
dominant motor  signs  because  of  pressure  upon  the  motor  bundles  of  the 
capsule,  while  affections  of  the  optic  thalamus  commonly  cause  hemi- 
anesthesia from  pressure  upon  the  posterior  fibres  of  the  capsule — 
carrefour  sensitif — or  destruction  of  sensory  fibres  within  the  thalamus 
and  often  hemianopsia  from  involvement  of  the  optic  radiations,  which  are 
collected  into  a  bundle  posterior  to  the  capsule  and  enter  the  optic  thala- 
mus. Mobile  spasm  or  athetosis,  associated  with  these  paralyses,  is  in 
favor  of  thalamic  lesion.  Weakness  of  the  articulatory  muscles  resembling 
bulbar  paralysis,  but  not  due  to  lesion  of  the  medulla  oblongata,  is  called 
pseudobulbar  paralysis.  It  is  most  often  due  to  multiple  hemorrhages  or 
softening  in  the  outer  part  of  the  lenticula. 

Lesions  of  the  corpus  callosum  are  revealed  by  disturbance  of  the 
functions  of  surrounding  parts,  notably  of  the  motor  zone, — as  shown  by 
early  epileptic  seizures,  by  paralyses,  and  symptoms  referable  to  the  pre- 
frontal region.  From  the  latter  arise  the  pseudoparetic  mental  states 
which  are  characteristic  of  callosal  lesion. 

4.   Aphasia  and   Other   Defects  of  Speech. 

Though  endowed  with  a  normal  brain,  the  individual  born  deaf  and 
blind  becomes  an  imbecile  by  deprivation  of  the  sense-impressions  out  of 
which  knowledge  grows,  unless  he  be  trained  like  Laura  Bridgman  through 
the  touch-sense.  The  cochlea,  the  retina,  etc.,  begin  the  transformation, 
from  mere  contact  with  the  external  world,  into  the  higher  special  sense- 
impressions.  These,  carried  by  their  separate  paths  to  the  cortex,  are 
elaborated  in  the  special-sense  centres  into  perceptions  of  things.  Roughly 
speaking,  each  cortical  centre  is  opposite  the  organ  of  that  sense.  Taking 
one  sense,  vision,  rays  of  light  from  an  object,  for  example  a  cow,  received 
by  the  retina  are  carried  through  the  visual  system  to  the  cuneus  as  sensa- 
tions of  form,  color,  etc.  Thence  passing  still  higher,  in  the  angular  gyrus 
is  formed  a  visual  image  of  a  cow — object-seeing — and  this  is  associated 
with  an  image  of  the  word  cow  written  or  printed — word-seeing.  Lesion 
of  angular  gyrus  then  does  not  cause  ordinary  blindness — as  lesion  of  the 
cuneus  does  in  one  half-field — but  loss  of  these  visual  images,  so  that  the 
patient  seeing  a  cow  can  hardly  tell  it  from  a  horse — object  mind-blind- 
ness; and  seeing  the  word  cow  fails  to  get  the  meaning  from  it,  as  if  it  were 
a  foreign  word — word-blindness.  In  like  manner,  close  to  the  auditory 
centre  is  a  higher  centre  for  the  formation  of  auditory  images,  by  which  a 
peculiar  sound  is  identified,  for  example,  as  the  lowing  of  a  cow — object- 
hearing — and  by  which  the  spoken  word  cow  is  recognized  as  the  name  of 
that   animal— word-hearing.      With   a   lesion   then   in   the   first   temporal 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  341 

convolution,  sparing  the  main  auditory  centre,  so  that  the  patient  is  still 
capable  of  hearing  noises,  there  may  be  loss  of  these  auditory  images  with 
consequent  object-deafness  and  word-deafness;  sounds  and  words  heard 
are  meaningless. 

To  speak  of  a  cow  it  is  necessary  to  recall  the  word  cow.  Many  persons 
are  likely  to  recall  a  word  as  it  sounds;  some  as  it  appears  written;  but 
most  revive  it  in  both  ways,  so  that  impairment  of  either  the  auditory  or 
the  visual  word-image  interfering  with  the  recollection  of  words  causes 
aphasia,  in  the  one  case,  from  lesion  of  the  angular  gyrus — visual  or  optic 
aphasia;  in  the  other,  from  lesion  of  the  first  temporal  convolution — audi- 
tory aphasia.  In  either  case  due  to  a  lesion  of  a  sensory  centre  it  is  spoken 
of  as  sensory  aphasia;  and  because  the  essential  defect  is  inability  to  recol- 
lect words  (verbal  amnesia)  both  are  included  under  the  term  amnesic 
aphasia.  The  act  of  speaking  involves  several  groups  of  muscles,  and  is 
interfered  with,  therefore,  in  various  forms  of  paralysis.  In  bulbar  paraly- 
sis, the  lips,  tongue,  etc.,  becoming  atrophied  and  paretic,  there  is  defect 
of  articulation,  incidentally;  and  in  the  similar  paralysis  from  cerebral 
lesion  (pseudobulbar  paralysis)  the  patient  may  be  inarticulate.  In  like 
manner  lesion  in  the  cortical  centres  for  the  lips,  tongue,  etc.,  at  the  foot 
of  the  motor  zone,  cripples  the  speech  just  as  lesion  in  the  leg  centre  causes 
limping;  so  here  on  the  emissive  side  of  the  speech-process  there  is  set 
apart  a  higher  centre  for  the  fine  adjustment  of  movements  in  uttering 
words,  and  for  the  memory  of  these  movements.  This  is  Broca's  centre, 
in  the  posterior  part  of  the  third  frontal  convolution.  By  lesion  here,  the 
muscles  of  articulation  still  intact,  the  patient  loses  his  motor  memories 
and  his  power  to  utter  words.    This  is  motor  aphasia — or  aphemia. 

Parallel  to  these  defects  of  articulation  are  defects  in  the  act  of  writing 
which  has  its  higher  centre  in  the  second  frontal  convolution,  related  to 
the  arm  centre  as  Broca's  is  to  the  centres  for  the  tongue,  lips,  etc.  Lesion 
in  the  writing  centre  causes  motor  agraphia,  even  though  the  arm  be  still 
useful  otherwise.  In  lesion  of  the  angular  gyrus,  as  the  appearance  of  words 
is  forgotten,  writing  is  imperfect;  there  is  sensory  agraphia.  In  reading 
aloud,  the  image  of  the  printed  word  must  be  conducted  from  the  angular 
gyrus  to  Broca's  centre,  there  to  be  matched  with  the  motor  image  used  in 
uttering  the  word;  and  the  utterance  must  be  guided,  too,  by  the  auditory 
image  conducted  from  its  centre.  For  this  purpose  Broca's  centre  is  con- 
nected with  the  others  by  tracts  of  fibres  which  being  damaged,  particu- 
larly in  the  insula — island  of  Reil,  there  is  interference  with  the  conduction 
referred  to,  and  hence,  with  reading  aloud  and  with  similar  uses  of  speech, 
conduction-aphasia.  For  perfect  speech  all  the  centres  must  act  in  unison 
through  conduction-paths  connecting  each  centre  with  the  rest,  and  con- 
sidering such  multiple  connections  it  is  evident  that  aphasia  of  some  kind 
may  result  from  lesion  at  any  point  within  a  wide  area.  This  "zone  of 
Language"  is  nearly  coextensive  with  the  distribution  of  the  middle  cere- 
bral artery,  and  aphasia  is  generally  a  consequence  of  apoplexy  from  this 
vessel,  commonly  in  association  with  hemiplegia.  This  same  region,  acting 
as  a  unit,  forms  a  complete  image  not  alone  of  the  won!  but  of  the  object 

also,  as  it  looks,  sounds,  feels,  smells,  tastes — in  short,  a  concept  .of  the 
object;   so  that  this  is  a  concept  area  (Mills). 


342  MEDICAL  DIAGNOSIS. 

Aphasia  being  a  curtailment  of  the  power  to  comprehend  as  well  as 
of  the  power  to  emit  language,  spoken,  written  or  by  signs — pantomime — 
care  and  system  in  testing  for  it  are  very  important.  "  Impediments"  of 
speech,  mechanical  imperfections  of  the  vocal  organs,  are  first  to  be  elimi- 
nated by  examination  of  the  mouth,  throat,  and  nasal  cavities.  In  cleft 
palate,  hypertrophic  rhinitis,  and  in  tongue-tie,  the  difficulty  is  mainly  in 
the  enunciation  of  consonants,  such  as  m,  n,  b,  etc. 

Dysarthrias,  from  paralysis  or  defective  innervation  of  the  muscles 
of  articulation,  are  to  be  recognized  partly  by  finding  additional  signs  of 
cerebral  paralysis  or  other  organic  nervous  disease,  and  partly  by  special 
characters  of  the  speech  in  certain  affections.  Somewhat  suggesting 
mechanical  impediment  is  the  speech  of  bulbar  paralysis,  marked  as  it  is 
by  labored  pronunciation  of  consonant-sounds. 

Elision  of  syllables  by  running  words  together,  may  be  observed  in 
hereditary  ataxia,  in  which  disease  speech  is  at  the  same  time  monotonous. 
These  two  characters  belong  also  to  the  speech  of  general  paresis,  forming 
with  the  difficulty  of  enunciating  the  r's  and  l's,  as  in  "  artillery,"  and  with 
its  tremulous,  measured  drawl,  the  peculiar  "paretic  speech"  which  is 
one  of  the  cardinal  signs  of  this  disease.  The  measured  character  of  such 
speech  exists  in  purer  form — scanning — in  disseminated  sclerosis. 

Ordinary  stuttering  is  a  pure  neurosis.  It  manifests  itself  by  spas- 
modic halting  in  attempts  to  utter  certain  words,  usually  those  beginning 
with  consonants. 

In  differentiating  aphasia  from  other  speech  defects  the  greatest 
difficulty  arises  in  the  case  of  actual  mental  loss — dementia — which  indeed 
may  coincide  with  aphasia,  as  in  hemiplegia  and  senility,  or  may  have 
aphasia  for  an  episodic  manifestation,  as  in  paresis. 

The  stubborn  speechlessness  frequently  met  with  in  paranoia  and 
melancholia  is  nearly  always  accompanied  by  other  signs  of  negativism, 
as  refusal  of  food  and  resistance  to  the  attentions  of  the  nurse.  Hysterical 
aphasia  is  intermittent  and  its  victim  exhibits  the  stigmata  of  the  neurosis. 
In  testing  an  apparent  aphasic  it  is  well  to  begin  on  the  sensory  side,  as- 
certaining whether  the  centres  for  word-hearing  and  word-seeing  are  impaired. 
A  number  of  common  objects  may  be  placed  before  the  patient  who  endeav- 
ors to  pick  out  those  named  in  turn  by  the  examiner  and  then  to  select  from 
a  list  of  names  on  paper,  that  of  the  object  selected  by  the  examiner. 

As  the  purpose  is  to  determine  the  clearness  of  word-images,  these 
simple  tests  are  essential;  but  the  examiner  may  progress  to  words  and 
sentences  of  any  complexity.  Rarely  being  complete,  aphasia  is  often 
betrayed  by  persistent,  helpless  misapplication  of  words,  the  patient  say- 
ing or  writing  for  instance  "dog"  when  a  hat  is  showed  to  him  and  its 
uses  demonstrated  by  him.  Paraphasia  and  paragraphia  are  forms  of 
aphasia  rather  characteristic  of  sensory  aphasia. 

To  test  a  patient's  emissive  power  of  language,  that  is,  to  discover 
motor  aphasia  and  agraphia,  objects  are  shown  to  him,  and  he  endeavors 
to  utter  and  write  their  names.  Simple  acts  performed  in  the  patient's 
presence  are  described  by  him  both  orally  and  in  writing.  In  motor  aphasia 
''recurring  utterances"  are  common,  a  patient  repeating  "any  one  any" 
or  other  meaningless  phrase  on  all  occasions  when  attempting  to  talk. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  343 

Even  after  demonstrating  that  a  patient  hears,  reads,  utters,  and 
writes  words  correctly,  and  thus  that  the  widely  separated  cortical  speech- 
areas  in  the  first  and  second  left  temporal  convolutions,  the  angular  gyrus, 
the  third  frontal  and  the  second  frontal  convolutions  are  probably  intact, 
together  with  the  subcortical  region  corresponding  to  each  centre,  we  may 
still  find  that  the  patient  is  much  crippled  in  the  use  of  language.  In  such 
a  case  we  conclude  that  some  of  the  fibres  connecting  these  cortical  centres 
with  one  another  are  cut  off,  and  that  we  are  dealing  with  a  case  of  "con- 
duction aphasia"  or  "transcortical  aphasia.''  The  prominent  features  of 
this  form  are  paraphasia,  paralexia,  etc.,  so  extreme  that  the  jumbling  of 
words  and  syllables  is  spoken  of  as  "jargon-speech."' 

So  entangled  in  these  "  association-systems"  are  all  the  cortical  centres 
that  speech-defect  from  cortical  lesion  always  betrays  some  features  of 
conduction  aphasia.  If  our  tests  reveal  uncomplicated  word-deafness  or 
word-blindness,  or  simple  loss  of  the  power  of  utterance,  we  recognize 
that  the  lesion  is  deep  in  the  brain,  beneath  the  level  of  association- 
systems,  where  the  fibres  radiating  to  or  from  the  particular  centre 
are  bundled  together.  This  is  called  "subcortical"  or  "pure"  aphasia, 
and  yet  some  evidence  exists  that  this  form  of  aphasia  may  result  from 
cortical  lesions. 

As  an  auxiliary  test  for  this  form,  the  study  of  pantomime  is  of  value. 
In  pure  motor  aphasia,  for  instance,  the  patient  though  speechless  as 
regards  utterance,  ma}-  when  asked  how  old  he  is,  open  and  shut  his  hand 
the  proper  number  of  times.     In  ordinary  motor  aphasia  this  is  impossible. 

5.   Spinal   Localization. 

One  of  the  consequences  of  modern  clinico-pathological  study  is  the 
tendency  to  interpret  nervous  symptoms  and  signs  in  relation  to  anatomical 
structure,  rather  than  in  relation  to  empirical  disease  forms.  This  tend- 
ency in  the  field  of  brain  disease  has  created  cerebral  localization;  and  it 
has  affected  our  conceptions  of  spinal  disease  to  the  extent  that  we  speak 
less  of  "locomotor  ataxia,"  of  "spastic  paraplegia"  or  of  "progressive 
muscular  atrophy"  as  disease  entities  than  as  dominant  symptoms  of 
various  lesions  affecting  certain  structures  of  the  spinal  cord.  Assuming 
in  this  connection  that  the  symptoms  in  a  given  case  are  of  spinal  origin, 
we  infer  from  "ataxia"  of  a  limb  that  the  dorsal  column  of  the  cord  is 
affected;  from  spasticity  with  increased  reflexes,  the  pyramidal  tract; 
from  atrophy,  the  ventral  horns  of  the  gray  matter;  from  anaesthesia,  the 
dorsolateral  column  again;  from  loss  of  pain-  and  temperature-sense  with- 
out anaesthesia — dissociation  of  sensation — the  central  part  of  the  gray 
matter;  from  pain,  the  dorsal  roots.  Then  we  endeavor  to  determine  the 
lesion  which  has  caused  the  particular  symptom-complex  which  confronts 
us  by  bringing  to  hem-  our  knowledge  of  the  natural  history  <>t'  nervous 
disease  and  by  collating  the  spinal  symptoms  with  any  cerebral  mani- 
festations which  may  be  present.  By  this  method  we  may  find  that  our 
"locomotor  ataxia"  case  is  really  one  .if  combined  degeneration  of  the 
cord  or  one  of  paresis,  ami  that  "progressive  muscular  atrophy"  is  symp- 
tomatic of  syringomyelia  or  of  tumor. 


344  MEDICAL  DIAGNOSIS. 

Spinal  localization  in  the  ordinary  sense,  however,  relates  to  diagnosis 
of  the  level  of  a  lesion  in  the  cord.  It  is  based  upon  our  accumulated 
knowledge  of  the  motor  sensory  reflex  and  sympathetic  control  exercised  by 
each  segment  of  the  spinal  cord  over  a  corresponding  segment  of  the  body. 

Injury  to  the  spinal  cord  at  any  point  involving  the  motor  trac 
unless  it  be  completely  severed — causes  paralysis,  with  increase  of  reflexes, 
below  that  point;  but  at  the  level  of  the  lesion  we  are  likely  to  find  the 
reflexes  abolished.  We  commonly  find  also  anaesthesia  covering  the  body 
below  this  level  if  the  lesion  is  grave,  and  the  upper  limit  of  anaesthesia, 
with  the  zone  of  absent  reflexes  coinciding,  is  the  best  index  to  the  level 
of  the  spinal  lesion.  If  the  lesion  affects  one  Lateral  half  of  the  cord  the 
above  principles  still  apply,  but  the  disturbance  of  sensation,  except  of 
the  sense  of  position,  is  found  on  the  side  opposite  to  that  of  the  lesion 
and  to  that  of  the  motor  symptoms — Brown-Sequard's  paralysis,  although 
even  in  this  form  tactile  sensation  is  often  preserved. 

The  level  thus  ascertained  marks  the  relative  position  of  the  lesion, 
but  its  actual  position  in  the  spinal  column  will  be  found  above  this,  gener- 
ally a  distance  of  about  three  spinal  segments.  A  aarrow  zone  of  anaesthesia 
is  usually  present  in  Brown-Sequard's  paralysis  on  the  side  of  the  lesion, 
and  at  its  level  and  above  this  may  be  a  narrow  zone  of  hyperesthesia 
Such  an  ansesthetic  zone  occurring  independently  points  to  a  lesion  outside 
the  cord  substance  and  involving  spinal  roots  of  at  least  two  segments. 
Sensory  loss  from  injury  to  the  cord  proper  or  the  posterior  root-  is  dis- 
tributed in  horizontal  bands  about  the  trunk  and  longitudinal  bands  in  the 
limbs,  irrespective  of  the  distribution  of  the  nerves — segmental  anaesthesia. 

The  clinician  should  be  able  to  conclude  off-hand  from  atrophy  of  the 
shoulder,  or  loss  of  reflexes  in  that  region,  that  the  upper  cervical  region  is 
affected  when  the  symptoms  are  of  spinal  origin;  from  such  symptoms 
affecting  the  forearm  and  hand,  that  the  lesion  Is  lower  down  in  the  cervical 
swelling;  from  loss  of  knee-jerk,  that  it  is  in  the  lumbar,  and  from  loss  of 
control  of  sphincters,  in  the  sacral  region;  but  for  finer  deductions  it  is 
well  to  record  the  findings  in  a  particular  case,  and  then  interpret  them 
by  reference  to  the  tables  and  diagrams  upon  pp.  326,  327  and  328. 

Combined  Degenerations. — "Typical  cases"  are  as  narrow  summits 
in  the  great  ranges  of  disease.  From  each  summit  the  symptomatology 
and  pathology  form  a  downward  slope,  by  which  that  disease  merges  with 
one  or  more  of  its  neighbors.  Of  lateral  sclerosis  very  few  absolutely  pure 
cases  have  been  reported.  On  the  one  hand,  in  cases  that  seem  like  pure 
lateral  sclerosis,  there  is  nearly  always  insidious  degeneration  in  the  ventral 
gray  horns — chronic  poliomyelitis;  or  the  latter  disease  after  a  course  of 
years  may  take  on  spastic  symptoms  because  the  pyramidal  tracts  are 
invaded,  that  is,  degeneration  beginning  in  either  motor  neuron  tends 
to  progress  to  the  other. 

In  some  cases  the  affection  of  superior  and  inferior  motor  neurons 
is  simultaneous,  progressive  muscular  atrophy  and  spastic  paraplegia 
developing  pari  passu.  Such  cases  constitute  amyotrophic  lateral  sclerosis. 
In  them  the  bulbar  part  is  prominent  and  degeneration  may  extend  even 
to  the  cortex,  mapping  out  the  motor  zone,  for  amyotrophic  lateral  sclerosis 
is  a  disease  of  the  whole  motor  system. 


PLATE  VII. 


6* to  l2*iriTE:RC0STAL 

HERVES     supply 
OBLIQUI  .TRANSVERSUS 
4  RECTUS 


GREAT  SPLAMCHMIC  MERVE 
SHALL 


ILIO- INGUINAL". 
IUO  -HYPOGASTRIC  n 

CEMITO  -CRURAL   am**    CREriASTER 

5  LUMBAR  NERVES 
supply  QUADRATUS 

6  PSOAS  J 


LEFT  PnEuriOCASTRIC 

HERVE    SUPPLIES     PHARYHX  . 
(ESOPHAGUS     4 
STOI1ACH . 


RIGHT 
PHEUnOGASTRIC  rl 


50LAR  PLEXUS 

SUPPLIES  ALL 
ABDOMiriAL  VISCEHA. 

5UP"MESEriTERIC 

PLEXUS  SUPPLIES  PANCREAS. 
SHALL  INTESTINE.   ILIO" 
COLON .  ASCENDING    5 
TRANSVERSE  COLOH. 


4*5"  SACRAL  M. 
LEVATOR  AI1I  & 
SPHIMCTER  AMI. 

COCCYGEAL  PLEXUS 


COCCYGEAL  MERVES   supply 
LEVATOR  AMI  »  SPHIMCTER  AMI 


plexus  on  the  sup" 

HEriORRHOIDAL 

VESSELS  supplies 
RECTun  4  Anus. 


RECTAL  iVE5ICAL 

PLEXUSES        SUPPLY 
RECTun  *  BLADDER. 


Connection  between  sympathetic  nerves  supplying  viscera  and  spinal  nerves  supplying  muscles  of 

abdominal  walls. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  345 

On  the  other  hand  degeneration  in  the  lateral  columns  may  be  accom- 
panied by  dorsal  degeneration.  Such  implication  of  superior  motor  neurons 
with  inferior  sensory  neurons  in  combined  degeneration  suggests  a  local, 
extraneous  cause,  acting  upon  the  lateral  and  posterior  columns  simul- 
taneously. The  mechanism  for  this  could  be  the  marginal  system  of 
arteries  carrying  some  toxin  into  these  portions  of  the  white  matter,  and 
the  lesion  might  be  expected  to  spread  around  the  arterioles  from  the 
very  margin  of  the  cord.  These  conditions  are  clearly  present  in  some  cases 
of  ergotism,  pernicious  anaemia,  etc.  An  acute  diffuse  dorsolateral  degen- 
eration may  be  found  at  autopsy,  though  commonly  no  symptoms  have 
been  observed  in  life.  In  various  undetermined  toxaemias  (Putnam  and 
E.  W.  Taylor)  a  subacute  degeneration  is  established,  partly  diffuse,  but  also 
partly  systematic,  as  in  time  it  enters  the  course  of  ascending  and  descend- 
ing tracts.  This  subacute  combined  degeneration  is  clinically  distinct 
from  the  other  types  (Russell,  Batten  and  Collier).  Possibly  similar  in 
origin  but  appearing  as  a  pure  combined  system  disease  (Striimpell) ,  the 
chronic  form,  posterolateral  sclerosis,  has  been  recognized  longer.  It  is 
manifested  clinically  by  paraplegia  from  the  pyramidal  tract  lesion,  with 
ataxia  from  the  lesion  in  the  dorsal  columns — ataxic  paraplegia  of  Gowers 
— but  without  lightning  pains  or  other  sensory  phenomena  and  without  eve- 
symptoms,  because  the  sensory  root-zones  and  roots — including  the  optic 
nerves — are  spared.  For  this  last  reason,  too,  the  reflexes  are  preserved 
in  posterolateral  sclerosis;  by  the  degeneration  of  the  pyramidal  tracts 
they  are  usually  increased  and  the  legs  made  spastic.  At  a  late  stage  the 
root-zones  may  be  invaded  and  reflexes  impaired  until  the  case  appears  like 
one  of  simple  tabes  dorsalis,  only  an  autopsy  revealing  the  combined  lesion. 

A  combined  sclerosis  is  the  commonest  spinal  lesion  of  paresis. 

6.   The   Reflexes. 

Every  segment  of  the  spinal  cord  contains  not  only  centres  for  certain 
groups  of  muscles  but  also  for  reflex  movements.  The  reflex  starts  in  an 
impulse  arising  from  the  stimulation  of  a  sensory  nerve.  It  is  transmitted 
to  a  centre  in  the  cord  and  passes  by  way  of  the  processes  of  the  sensory 
cell-bodies  to  the  neurons  of  the  corresponding  motor  centre,  in  which  it 
originates  a  motor  impulse  which  in  turn  passes  by  way  of  the  motor  nerve 
to  the  muscle-fibres  supplied  by  the  nerve.  This  complete  path,  made  up 
of  centripetal  or  sensory  fibres  with  their  cell-bodies  and*  correlated  cell- 
bodies  with  their  centrifugal  or  motor  fibres,  is  called  a  reflex  arc.  The 
sensory  impulse  may  bo  transmitted  to  centres  at  higher  or  lower  levels 
and  excite  several  motor  impulses,  thus  producing  a  complicated  reflex  arc. 
The  cord  segments  are  connected  with  fibres  from  the  cerebrum  having 
the  function  of  inhibiting  the  reflex.  If  these  fibres  are  irritated  t  he  reflexes 
are  impaired  from  abnormal  inhibition;  if  they  are  destroyed  the  reflexes 
are  exaggerated.  If  the  arc  is  interrupted  either  in  its  afferent  or  efferent 
limb  or  in  the  centre  the  reflex  is  lost. 

Involuntary  contraction  of  muscles  aroused  by  a  sensory  impression 
upon  related  parts  is  a  reflex  in  the  ordinary  sense.  For  fine  deductions 
the   muscles  themselves  must  be  observed.     The  quadriceps   cruris,   for 


346  MEDICAL  DIAGNOSIS. 

example,  may  be  seen  to  contract  on  tapping  the  patellar  tendon,  even 
when  no  motion  of  the  leg  occurs,  and  under  such  circumstances  the  "  knee- 
jerk"  cannot  be  said  to  be  abolished;  but  ordinarily  we  recognize  reflex 
response  in  muscles  by  a  characteristic  motion  imparted  to  a  member,  as 
the  kicking  movement  of  the  leg  which  is  regarded  as  a  measure  of  the 
knee-reflex. 

Absence  of  the  usual  motor  response,  of  the  knee-jerk  for  example, 
or  its  diminution  or  exaggeration,  are  the  matters  to  be  attended  to  in  the 
study  of  most  reflexes,  particularly  the  "tendon-reflexes."  This  is  true 
also  of  most  of  the  superficial — skin — reflexes,  though  in  certain  of  them 
the  character  of  the  motion  elicited  is  significant;  thus  with  the  plantar 
reflex,  flexion  of  the  toes  is  normal,  while  extension — Babinski  reflex — 
indicates  lesion  of  the  pyramidal  tract  of  the  corresponding  side,  extension 
of  the  toes  being  equivalent  to  exaggeration  of  other  reflexes.  In  a  third 
group,  the  so-called  periosteal  reflexes,  any  motion  of  the  member  estab- 
lishes the  presence  of  the  reflex,  as  in  the  case  of  the  scapulohumeral, 
the  motion  of  which  may  be  external  or  internal  rotation,  and  ad-  or  ab- 
duction of  the  upper  arm,  according  as  to  which  of  the  muscles  attached 
to  the  scapula  are  most  actively  excited  when  this  bone  is  jarred  by 
tapping  at  a  spot  where  it  is  bare  save  of  periosteum  and  skin. 

A  reflex  must  be  fairly  constant  and  discernible  in  the  normal  subject 
to  give  much  significance  to  its  alterations,  particularly  to  its  absence. 
Many  reflexes  are  of  minor  clinical  importance  because  they  are  present 
in  only  a  small  percentage  of  normal  subjects  and  then  are  not  pronounced, 
the  ulnar  for  instance.  Reflexes  of  the  lower  extremity  are  on  the  whole 
more  important  than  those  of  the  upper,  and  the  knee-jerk  is  preeminent 
in  this  respect. 

The  reflexes  of  the  upper  extremity  being  inconstant,  absence  of  any 
one  of  them  signifies  little;  exaggeration  of  one  has  a  certain  value;  and 
even  the  marked  presence  of  a  number  of  them  in  a  patient  has  something 
of  the  import  of  exaggeration  of  other  reflexes. 

Knee=jerk  or  Patellar  Tendon  Reflex. — To  elicit  the  knee-jerk  the 
leg  is  rendered  passive  by  crossing  the  knee  over  its  fellow,  or  by 
supporting  it  on  the  examiner's  forearm  passed  under  the  patient's  knee 
and  braced  by  the  hand  placed  upon  the  other  knee,  or  by  having 
the  patient  while  recumbent  draw  up  his  knee  into  an  easy  position 
with  all  muscular  tension  on  his  part  withdrawn;  the  patellar  tendon  well 
below  the  knee-cap  is  then  struck  a  firm,  quick  blow  with  the  ulnar  edge 
of  the  hand  or  with  a  percussion  hammer. 

The  knee-jerk  should  never  be  declared  absent  until  Jendrassik's 
method  of  reinforcement  has  confirmed  the  result.  This  is  applied  by 
directing  the  patient  to  hook  his  hands  together  and  to  keep  them  so  while 
tugging  at  them  as  if  to  pull  them  apart.  It  is  customary  for  the  examiner 
to  count  "one,  two,  three"  after  instructing  the  patient  to  "pull  hard" 
at  "three,"    the  tap  on  the  tendon  being  made  at  about  "four." 

The  signs  +  for  increased  and  —  for  diminished  knee-jerks  are  com- 
monly employed;    and,  in  writing,  "kj"  for  the  reflex  itself  is  allowable. 

The  knee-jerk  being  due  to  contraction  of  the  quadriceps  cruris 
muscle,    the    essential    phenomenon    may    be    induced    by    tapping    the 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


347 


muscle  itself  just  above  the  patella,  especially  if  the  latter  is  pressed 
downward  by  a  finger  laid  along  the  upper  edge  of  the  bone  and  this 
finger  is  then  tapped  with  the   hammer. 


Fig.  133. — Method  of  testing  patellar  reflex. 


Fig.  134. — Achilles  tendon  reflex. 


Babinski    Reflex. — In  testing  for  the   Babinski  reflex  the  examiner 
supports  the  patient's  ankle  with  his  left  hand  and  strokes  the  sole  of  the 


In;.  1 35.     Plantar  flexion, 


foot   with  any  objed    which   makes  a  distinct   sensory  impression-  a  sonie- 

wli.-it  sharp  point  being  necessary  when  the  skin  is  thick     at  the  same  time 
noting  the  movement  of  the  toes,  which  in  all  normal  person-  past  the  age 


348 


MEDICAL  DIAGNOSIS. 


of  infancy  is  plantar  flexion.  Extension  (dorsiflexion)  of  the  toes,  partic- 
ularly of  the  big  toe,  elicited  in  this  way  constitutes  the  Babinski  reflex, 
which  is  a  most  impoitant  sign  of  involvement  of  the  pyramidal  tracts. 


Fig.  136. — Babinski  reflex  (dorsiflexion  of  the  toes). 


Ankle  Clonus. — This  phenomenon  usually  accompanies  a  considera- 
bly increased  knee-jerk,  and  has  a  similar  significance.  To  test  for  it,  the 
whole  leg  should  be  relaxed — best  by  having  the  patient  supine.     The 


Fig.  137. — Biceps  reflex. 


examiner's  left  hand  supports  the  leg,  and  his  right,  clasping  the 
patient's  foot,  presses  it  upward,  when,  if  clonus  is  present,  the  foot  is 
pushed  back  against  the  hand  in  a  series  of  jerks  which  are  due  to  clonic 
spasm  of  the  (soleus)  muscle. 


EXAMINATION   OF   THE    NERVOUS   SYSTEM. 


349 


Achilles  Jerk. — A  single  reflex-contraction  of  the  calf  muscle  may  be 
induced  by  tapping  the  tendon,  which  the  examiner  has  rendered  tense  by 
pressing  the  foot  upward.  This  reflex  is  called  the  Achilles  jerk  and  is  an 
index  of  the  condition  of  the  sciatic  nerve  and  corresponding  segments 
of  the  spinal  cord.  It  is  best  obtained  by  having  the  patient  kneel  upon  a 
chair  while  the  examiner  taps  the  Achilles  tendon. 

The  Abdominal  Reflex. — This  reflex,  quite  a  constant  one,  is  elicited 
by  stroking  the  side  of  the  abdomen.  The  ensuing  contraction  is  wide- 
spread over  this  region. 

The  Cremasteric  or  Inguinal  Reflex  consists  in  a  drawing-up  of  the 
scrotum  and  testicle  on  stroking  the  inside  of  the  thigh. 

The  Epigastric  Reflex. — On  stroking  along  the  costal  margin  the 
muscles  over  the  pit  of  the  stomach  contract. 

Among  the  reflexes  of  the  upper  extremity,  the  Radial — a  periosteal 
reflex — is  elicited  by  tapping  above  the  styloid  process  of  the  radius,  and 
consists  mainly  in  flexion  at  the  elbow-joint.    The  nearly  identical  motion 


Fig.  138. — Triceps  reflex. 


of  the  Biceps  Reflex  arises  when  the  tendon  of  this  muscle  is  tapped  at  the 
bend  of  the  elbow.  In  testing  the  last  two  reflexes  the  examiner  places 
his  forearm  under  that  of  the  patient,  in  order  to  relax  the  latter. 

To  elicit  the  Triceps  Reflex  the  patient's  upper  arm  is  given  a  fixed 
support  on  the  examiner's  wrist  or  on  a  chair-back,  when  tapping  above  the 
olecranon  causes  an  outward  jerk  of  the  forearm. 

Plantar  Reflex. — Produced  by  tickling  the  sole  of  the  foot.  It  consists, 
when  fully  developed,  of  sudden  withdrawal  of  the  foot  by  flexion  at  the 
hip  and  knee,  dorsal  flexion  of  the  ankle  and  plantar  flexion  of  the  toes. 
The  movement  in  undeveloped  cases  may  consist  of  sudden  plantar  flexion 
of  the  toes.  It  occurs  in  normal  conditions,  but  in  varying  degrees.  There 
are  those  who  have  the  power  to  voluntarily  prevent  it.  This  reflex  is 
exaggerated  in  neurasthenia,  hysteria  and  other  functional  diseases  of  the 
nervous  system,  and  may  be  associated  in  extreme  cases  with  general 
convulsive  movements  or  may  be  crossed, — that  is,  it  may  occur  on  the 
opposite  side,  as  well  as  on  the  side  tickled.  It  is  also  increased,  but  usually 
to  a  moderate  extent  only,  in  organic  disease  of  1  he  cent  ral  nervous  system. 

It  is  as  a  rule  abolished  in  the  affected  Bide  iii  hemiplegia  and  invariably 
absenl  in  destructive  lesions  involving  the  sensory  nerves  of  the  legs. 
Other  reflex*  s  of  minor  clinical  Importance  are: 


350  MEDICAL   DIAGNOSIS. 

The  Supraorbital  Reflex. — Produced  by  a  sharp  tap  upon  the  trunk 
of  the  supra-orbital  nerve,  it  consists  of  slight,  momentary  contractions  of 
the  orbicularis  palpebrarum,  especially  in  its  external  half.  It  is  absent  in 
destructive  lesions  of  the  supra-orbital  nerve  and  in  peripheral  facial  palsy. 

The  Malar  Reflex. — Not  usually  present  in  normal  conditions,  but 
caused  in  recent  facial  paralysis  of  peripheral  origin  by  percussion  over 
the  malar  bone.  It  consists  of  contraction  of  the  elevator  of  the  angle  of 
the  mouth  and  movements  of  the  ala  nasi. 

The  Chin  Reflex. — This  phenomenon  is  elicited  by  tapping  upon  a 
small  flat  object,  as  an  ivory  paper  cutter  or  a  tongue  depressor,  laid  upon 
the  lower  front  teeth,  or  the  finger  laid  upon  the  protuberance  of  the  chin 
when  the  mouth  is  open  and  the  jaw  relaxed  and  drooping.  The  response 
consists  in  a  sharp  upward  movement  of  the  jaw.  It  may  be  present  in 
nervous  conditions,  as  hysteria,  and  in  cachectic  states. 


Fig.  139. — Paradoxical  reflex. 

The  Femoral  Reflex. — Not  present  in  health.  It  is  produced  in  trans- 
verse lesions  of  the  spinal  cord  above  the  level  of  the  eighth  dorsal  seg- 
ment by  irritation  of  the  anterior  surface  of  the  upper  part  of  the  thigh, 
and  consists  in  plantar  flexion  of  the  toes  and  extension  of  the  foot. 

Sinkler's  Toe  Reflex. — Produced  by  sudden  forcible  flexion  of  the  great 
toe.  It  consists  in  forcible  flexion  of  the  knee  and  hip  and  is  met  with  in 
spastic  conditions  arising  In  spinal  disease,  as  spastic  paraplegia. 

Gowers's  Front  Tap. — The  leg  being  slightly  flexed,  a  blow  is  struck 
upon  the  tibialis  anticus  muscle.  Plantar  flexion  of  the  toes  occurs  in  a 
considerable  proportion  of  normal  persons,  many  neurasthenic  and  hysteri- 
cal individuals,  and  not  at  all  in  tabes. 

Paradoxical  Reflex. — Caused  by  sudden  shortening  of  the  tendon; 
elicited  by  deep  pressure  upon  the  calf  muscles,  and  consisting  in  extension — ■ 
dorsiflexion — of  the  toes,  especially  the  great  toe.  It  is  regarded  as  a  sign 
of  irritation  or  early  organic  affection  of  the  motor  pathway. 

Oppenheim's  Reflex. — Dorsiflexion  of  the  toes  and  foot  upon  forcibly 
stroking  the  skin  along  the  inner  border  of  the  tibia. 

Pfliiger's  Laws — l.  The  reflex  occurs  upon  the  same  side  of  the  body 
as  that  to  which  the  irritant  is  applied  and  in  muscles  whose  motor  nerves 
arise  from  the  same  segments  of  the  cord.  2.  If  the  reflex  occurs  on  the 
opposite  side,  only  the  corresponding  muscles  contract.  3.  If  the  reflexes 
are  unequal  on  the  two  sides,  the  stronger  are  on  the  side  upon  which  the 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  351 

irritation  has  been  applied.  4.  'When  the  reflex  extends  to  other  segments 
the  direction  of  the  extension  is  toward  the  medulla.  5.  All  the  muscles 
of  the  body  may  yield  reflexes. 

Kernig's  Sign. — Xot  a  true  reflex  but  conveniently  described  in  this 
connection.  Normally  the  leg  may  passively  be  fully  extended  on  the  thigh, 
when  the  latter  is  at  right  angles  to  the  long  axis  of  the  trunk,  as  when  the 
patient  sits  upon  the  edge  of  the  bed  with  his  legs  hanging  down,  or  has  the 
thighs  flexed  when  in  the  recumbent  posture.  The  extending  force  must  be 
moderate  and  gradual.  Resistance  and  pain  are  developed  at  an  angle 
between  95°  and  135°.  This  sign  occurs  in  acute  meningitis,  especially 
cerebrospinal  fever,  when  collapse  symptoms  are  absent,  but  is  not  con- 
It  ant  in  tuberculous  meningitis.  It  has  been  variously  ascribed  to  irrita- 
tion of  the  meninges  and  posterior  nerve  roots,  irritative  lesions  of  the 
pyramidal  tract,  intraventricular  pressure,  and  cerebellar  irritation.     It 


FlG.  140  —  Oppenheim's  reflex. 

occurs  in  various  acute  diseases  in  young  children  and  very  rarely  in  adults 
in  enteric  fever.  It  may  be  simulated  in  old  age,  disuse  of  the  lower  limbs, 
arthritis,  sciatica,  and  contractures. 

Brudzinski's  Sign. — If  the  head  is  flexed  upon  the  chest,  flexion  of  the 
legs  at  the  hips  and  knees  occurs  and  flexion  of  one  thigh  upon  the  trunk 
causes  a  movement  of  the  same  kind  on  the  other  side. 

7.  Electrodiagnosis. 

For  diagnostic  purposes  the  galvanic  battery  is  more  important  than 
the  faradic;  but  each  gives  considerable  information  as  to  the  cause  and 
character  of  motor  paralysis  or  the  variety  of  muscular  atrophy  present, 
and  the  prognosis  in  paralysis  and  atrophy  of  certain  kinds. 

The  electrodes,  covered  with  absorbent  cotton  and  wetted,  are  placed 
upon  the  patient's  bare  skin,  one  at  some  "indifferent"  point,  as  the  back 
of  the  neck,  the  other  upon  the  part  to  be  examined — motor  point  of  the 
muscles  or  the  nerve-trunks.  With  a  faradic  current  thus  applied,  on 
opening  the  circuit  a  quick  contraction  of  the  muscles  ensues  in  the  region 
of  the  distal  electrode,  whether  this  be  positive  (the  anode)  or  negative 
(the  cathode);  but  if  the  interruptions  are  rapidly  repeated  the  muscle  is 
thrown  into  a  tetanic  state.  If  these  muscles  be  the  seat  of  paralysis  from 
lesion  of  the  inferior  motor  neuron — poliomyelitis,  neuritis,  etc. — or  if 
they  be  atrophied,  their  response  to  the  faradic  current  is  diminished  in  a 
degree  which,  after  sonic  experience,  can  l>c  estimated  by  the  examiner. 


352 


MEDICAL  DIAGNOSIS. 


Fig.  141. — Motor  points. 


1,    frontalis;    2,    eorrugator    ™^^^$g%$£^L  ti 


bicepirbrachialis  an tTc'usV  supinator  longus);  82,  anterior  thoracic  nerve  (pec *££,"%£"£££  abdominis 
nerve  (deltoid);    34,  long  thoracic  nerve  (serratus  magnus);    35,  brachial  plexus,    d^reeius 
(nervi  intercostales  abdominales):     37,   serratus  magnus;     38,   latissimus  dorsi,     ay,   ODiiquua  * 
externus  (nervi  intercosta.es  abdominales);    40,  transversus  abdominis 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


353 


This  diminution  of  faradic  contractility  serves  as  an  early  index  of  the 
extent  of  paralysis  and  atrophy  which  is  likely  to  appear  in  acute  anterior 


Fro.  142. — Motor  points  1,  musculocutaneus;  2,  caput  interims  m.  tricipitis;  3,  n.  museuloeu- 
taneus;  4,  biceps;  5,  medianus;  6,  brachials  internus;  7,  n.  ulnaris;  8,  rami  d.  mediani  pro  m.  pmnatore 
radii  terete;  9,  palnians  longus;  10,  radialis  internus;  11,  ulnaris  internus;  12,  flexor  digitorum  pro- 
fundus; 13,  flexor  digitorum  sublimis;  14,  flexor  digitorum  sublimis  (digitt.  11  et  111);  15,  n.  ulnaris; 
16,  flexor  digitorum  sublimis  (digitt.  indicia  et  minim. >;  17,  flexor  pollicis  longus;  18,  medianus;  19, 
abduetor  pollicis  brevis;  20,  rami  volar,  prof,  nervi  ulnaris;  21,  pahnaris  brevis;  22,  abductor  digiti 
minimi;  23,  flexor  digiti  minimi;  24,  opponens  digiti  minimi;  25,  lumbricales  II,  III  el  I\;  26,  opponens 
pollicis;  27,  flexor  pouicie  brevis;  28,  adductor  pollicis;  29.  lumbncalis  I;  30,  caput  externus  m.  tricipitis; 
31,  n.  radialis;  32,  brachialis  internus;  33,  supinator  longus;  34,  radialis  externus  longus;  3.">,  radialis 
externus  brevis;  36,  extensor  digitorum  communis;  37,  ulnaris  internus;  38,  extensor  digiti  minimi 
proprius;  39,  extensor  indicis  propriusj  40,  extensor  indicis  prop,  et  abductor  pollicis  longus;  41,  abduc- 
tor pollicis  longus;  42,  extensor  pollicis  brevis;  43.  extensor  pollicis  longus;  44,  flexor  pollicis  longus; 
45,  interosseue  dorsalis  I;  - 1 * ■ ,  abductor  digiti  minimi;  47,  interosseus  dorsalis  IV;  4.s,  interosseus 
dorsalis  III;  49,  interosseus  dorsalis  ll 


poliomyelitis,  in  Bell's  palsy,  or  other  disease  inducing  rapid  degeneration 
of  muscles;   but  at  the  end  of  two  weeks  from  t he  onset  in  these  affections 
there  is  commonly  no  response  whatever  to  faradism. 
23 


354 


MEDICAL  DIAGNOSIS. 


On  the  other  hand,  if  the  galvanic  current  be  applied  as  described 
above  over  paralyzed  or  atrophied  muscles  the  contractility  is  found  to  be 
at  first  increased;  that  is,  galvanic  hyperexcitability  is  a  sign  of  muscle 


14 


lit 


Fig.  143. — Motor  points.  1,  anterior  crural  nerve;  2,  tensor  fascia  lata?;  3,  sartorius;  4,  obturator 
nerve;  5,  pectineus;  6,  quadriceps  (common  point);  7,  rectus  femoris;  8,  adductor  longus;  9,  adductor 
magnus;  10,  gracilis;  11,  crureus;  12,  vastus  externus;  13,  vastus  internus;  14,  external  popliteal 
nerve;  15,  peroneus  longus;  16,  extensor  longus  digitorum;  17,  tibialis  anticus;  18,  peroneus  brevis; 
19,  extensor  hallucis  longus;  20,  extensor  brevis  digitorum;  21,  dorsal  interossei'  22,  gluteus  maximus; 
23,  adductor  magnus;  24,  sciatic  nerve;  25,  semitendinosus;  26,  gracilis;  27,  biceps  (long  head);  28, 
semimembranosus;  29,  biceps  (short  head);  30,  internal  popliteal  nerve;  31,  external  popliteal  nerve; 
32,  gastrocnemius  (outer  head);  33.  gastrocnemius  (inner  head);  34,  soleus;  35,  flexor  longus  digitorum; 
36,  flexor  longus  hallucis;    37,  posterior  tibial  nerve. 


degeneration.  Later  it  diminishes.  Contraction  of  the  muscles  under  the 
galvanic  current  is  only  momentary,  appearing  both  on  closing  and  on 
opening  the  circuit.  The  various  responses  of  the  normal  muscle  are  as 
follows :  To  the  negative  pole,  or  cathode,  the  first  or  most  active  response 
is  on  closing  the  circuit,  which  is  expressed  thus,  CCC.  On  opening  the 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  355 

circuit  there  is  no  response,  C  O  C.  To  the  positive  pole,  or  anode,  a 
response  not  so  active  as  to  the  cathode  is  obtained  on  closing  the  circuit, 
A  C  C  ,  and  occasionally  a  response  is  also  obtained  on  opening  the  circuit, 
especially  if  the  pole  is  held  on  the  trunk  of  a  motor  nerve,  A  O  C.  These 
two  responses  to  the  anode  may  be  about  equal,  but  usually  the  response 
at  closure  is  greater  than  at  opening,  and  neither  is  as  active  as  the  response 
to  the  closure  of  the  cathode.    Thus  the  normal  formula  stands  as  follows: 

C  C  C    >  A  C  C    >  or  =  A  0  C    >  C  0  C. 

This  formula  represents  what  we  find  practically  at  the  bedside. 
There  are  some  distinctions  between  the  responses  to  nerve-tissue  on  the 
one  hand  and  muscle-tissue  on  the  other,  as  observed  in  laboratory  experi- 
ments on  animals;  but  these  need  not  detain  and  confuse  us  here. 

Reaction  of  Degeneration — R.  D. — When  a  muscle  is  degenerating — 
for  instance,  when  it  is  cut  off  from  its  nerve  supply  either  by  injury  or 
disease  (nerve  injuries,  neuritis,  acute  anterior  poliomyelitis) — the  reactions 
to  galvanism  are  altered.  The  anodal  closure  contraction  becomes  greater 
than  the  cathodal  closure  contraction,  A  C  C  >  C  C  C  ,  although  both  are 
diminished  as  compared  with  those  of  the  normal  muscle.  At  the  same  time 
the  anodal  opening  contraction  (never  very  conspicuous)  disappears,  and  very 
rarely  the  cathodal  opening  contraction  is  seen.  Thus  the  typical  reaction 
of  degeneration  is  as  follows:  ACC  >CCC  (COC  sometimes  seen,  A 
O  C  disappearing).  The  response  of  degenerating  muscle  is  sluggish,  not 
quick  and  active. 

8.  Trophic  Disturbances. 

In  a  broad  sense  all  disease  is  nutritional  disorder;  but  there  are  some 
diseases  which  directly  attack  the  nervous  structures  presiding  over  nutri- 
tion of  related  parts  of  the  body,  and  these  are  properly  "trophic  diseases." 
The  nutritional  disorder  may  be  the  principal  manifestation  of  the  disease, 
as  is  indeed  recognized  in  the  very  name  of  the  group  of  muscular  atrophies. 
Whether  or  not  there  be  separate  trophic  nerve-fibres,  we  know  that  for 
the  muscles  the  trophic  impulses  traverse  the  motor  nerves  chiefly.  If 
motor  pals\  »'s  accompanied  by  rapid  wasting,  the  lesion  is  probably  in  the 
gray  matter  (of  the  cord,  oblongata,  etc.)  or  in  the  peripheral  nerves, 
since  toey,  comprising  the  lower  motor  neurons,  preside  over  nutrition 
most  directly.  But  sicw  wasting  may  affect  parts  paralyzed  by  cerebral 
disease  (upper  motor  neurons),  the  affected  side  in  old  hemiplegia  being 
commonly  much  atrophied.  This  is  ascribed  to  involvement  of  trophic 
centres  in  the  cortex.  While  the  spastic  spinal  palsies  arise  from  disease 
of  superior  motor  neurons — pyramidal  tracts — they  often  manifest 
atrophy  which  may  be  similar  in  all  respects  to  that  of  chronic  poliomye- 
litis— ordinary  progressive  muscular  atrophy.  In  such  cases  there  is  no 
physiological  paradox:  the  atrophy  is  referable  to  implication  of  the  gray 
matter  of  the  cord.  Primary  lateral  sclerosis  is  practically  always  accom- 
panied by  atrophy,  distributed  as  in  poliomyelitis,  which  implies  that  the 
two  -motor  neurons— superior  and  inferior — are  perhaps  independently, 
though  simultaneously,  involved,  and  bulbar  palsy  is  frequently  included 
in  the  clinical  picture.     It  is  well,  therefore,  to  conceive  of  chronic  polio- 


356 


MEDICAL  DIAGNOSIS. 


myelitis,  lateral  sclerosis,  amyotrophic  lateral  sclerosis  and  bulbar  palsy 
as  constituting  one  disease,  of  which  a  particular  symptom — atrophy, 
etc. — is  dominant  in  each  of  the  types  named. 

The  distribution  of  muscular  atrophy  has  considerable  significance, 
especially  the  region  of  the  body  in  which  it  first  appears.  Atrophy  begin- 
ning in  the  small  muscles  of  the  hand,  or  in  the  shoulder,  is  generally  pro- 
gressive— spinal — muscular  atrophy. 

In  the  "family  type"  of  spinal  atrophy  appearing  in  infancy,  the 
muscles  of  the  legs  and  back  are  the  first  to  show  wasting.  The  myopathies 
or  muscular  dystrophies  are  likely  to  appear  first  in  the  pelvic  girdle  (leg 
type),  in  the  shoulder  girdle  (arm  type),  or  in  the  face  (face  type).  When 
atrophy  occurs  in  the  foot  and  outer  lower  leg — peroneal  muscles — the 
so-called  primary  neuritic  atrophy  is  to  be  considered. 

The  cardinal  tests  of  spinal,  as  distinguished  from  idiomuscular,  atro- 
phies are  the  electrical  reaction  of  degeneration  and  fibrillary  twitching, 
both  present  in  the  former,  and  absent  in  the  latter  or  myopathies. 


Fig.  144. — Bed-sores. — German  Hospital. 


The  muscles  above  or  below  a  diseased  joint  often  waste.  This  is 
called  "  arthritic  atrophy,"  and  is  explained  as  a  reflex  phenomenon  set 
up  by  irritation  of  sensory  nerves  supplying  the  joint. 

The  clinician  must  discriminate  between  the  atrophy  from  disuse  or 
from  joint  disease,  and  that  which  is  the  essential  manifestation  of 
certain  grave  nervous  diseases;  and  he  does  so  mainly  by  considering 
the  correlated  symptoms  and  signs. 

Certain  diseases  are  presumably,  though  not  manifestly,  trophic  in 
origin;  as  arthritis  deformans.  Others,  such  as  acromegaly,  myxcedema, 
and  adiposis  dolorosa,  result  from  disease  of  ductless  glands — pituitary 
body,  thyroid — through  the  medium  of  the  trophic  nervous  apparatus, 
which  is  affected  by  the  absence  or  derangement  of  the  secretions  of  these 
glands.  These  diseases — characterized  respectively  by  gross  enlargement 
of  hands,  feet,  and  face;  by  thickened,  doughy  skin;  by  great  masses  of 
painful  fat — illustrate  trophic  excess,  hypertrophy,  and  hyperplasia. 

Still  another  group  of  affections,  pathologically  obscure  and  clinically 
indefinite,  illustrate  trophic  disease  arising  through  the  medium  of  vaso- 
motor derangement.  These  comprise  angioneurotic  oedema,  acropares- 
thesia, Raynaud's   disease,    erythromelalgia,   and    perhaps  other  diseases. 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


357 


A  variety  of  local  affections  occur  however  as  incidents,  more  or  less 
important,  in  the  course  of  organic  nervous  diseases,  and  constitute  trophic 
manifestations  of  these  diseases,  just  as  paralysis  and  anaesthesia  constitute 


Fig.  145. — Ataxic  elbow-joint. — Young. 


their  motor  and  sensory  manifestations.  These  trophic  disturbances  some- 
times resemble  independent  affections  and  the  nervous  diseases  underlying 
them  may  thus  be  overlooked,  for  instance,  bed-sores  in  emaciation  or 
sprains  in  Charcot  joints.     A  joint  affection,  especially  if  it  be  subacute  or 


Fro.  140. — PorforatinR  ulrprs  of  the  f"<>t. — German  Hospital. 

chronic  and  confined  to  one  or  two  joints,  is  often  of  nervous  origin.  In 
acute  myelitis  inflammatory  arthropathies,  resembling  rheumatism,  may 
arise.  In  old  hemiplegia — on  the  paralyzed  side — and  in  various  chronic 
cord-diseases,  an  osteo-arthritis  is  not  uncommon.  The  classic  form  is 
the  Charcot  joint,  which  occurs  most  frequently  early  in  the  course  of 


358  MEDICAL  DIAGNOSIS. 

tabes  dorsalis.  The  arthropathy  of  syringomyelia  often  affects  the  spine, 
inducing  scoliosis.  Painless  whitlows  of  fingers  or  toes  call  for  study  of 
sensation  in  these  parts,  for  if  they  betray  loss  of  temperature  and  pain 
sensibility,  we  are  dealing  with  "Morvan's  disease,"  a  trophic  manifesta- 
tion of  syringomyelia.  Painless  perforating  ulcer  of  an  extremity,  often 
on  the  ball  of  the  foot  or  great  toe,  belongs  commonly  to  tabes  dorsalis  or 
to  syringomyelia.  Bed-sores  form  usually  at  spots  injured,  especially  over 
the  sacrum  from  pressure  of  the  bed,  but  the  extent  of  the  ulceration  is 
ordinarily  out  of  proportion  to  the  apparent  cause.  Moreover,  sloughs  do 
form  without  external  cause,  from  purely  trophic  defect.  The  skin  shows 
changes  in  various  nervous  diseases,  as  do  the  nails,  hair  and  other 
structures  histologically  allied  to  the  skin.  "  Glossy  skin," — shiny,  thin, 
dry  epidermis  on  the  extremities, — results  from  neuritis  of  somewhat  long 
duration.  The  vesicles  of  herpes  zoster  are  a  trophic  manifestation  of 
neuritis,  most  frequently  intercostal. 

9.   Pain   and   Temperature. 

In  ordinary  anaesthesia,  as  that  of  neuritis  or  of  tabes  dorsalis,  loss  of 
sensibility  to  pain,  and  to  heat  and  cold,  is  associated  with  the  loss  of 
touch  sense.  The  .nerves  and  dorsal  roots,  the  seat  of  these  diseases,  con- 
tain the  fibres  for  all  forms  of  sensation. 

There  is  a  remarkable  condition,  however,  in  which  a  patient,  though 
feeling  himself  touched  by  an  object — touch  sensation  preserved — cannot 
tell  whether  it  k  hot  or  cold — temperature  sense  lost — or  whether  it  is 
sharp  or  dull — pain  sense  lost.  This  separate  sensory  loss  is  called  disso- 
ciated anaesthesia.  It  is  in  the  root-zone  that  the  pain  and  temperature 
fibres  part  company  with  all  others  to  enter  the  gray  matter  and  sweep 
across  by  way  of  the  commissure  to  the  opposite  margin  of  the  cord. 

In  the  neighborhood  of  the  central  canal — central  gray  matter — the 
pain  and  temperature  fibres  from  one  side  decussate  with  those  from 
the  opposite  side  in  a  narrow  space,  and  a  small  lesion  at  this  point, 
sparing  the  dorsal  columns,  may  cause  dissociate  anaesthesia.  The  lesion 
that  most  often  occurs  here  is  a  peculiar  tumor  that  forms  by  prolifera- 
tion of  neuroglia  just  back  of  the  central  canal. 

When  proliferated  rapidly  neuroglia  forms  a  soft  mass.  In  the  brain 
where  its  commonest  seat  is  deep  in  the  cerebellum,  it  meets  equal  pres- 
sure on  all  sides  and  so  becomes  globular — glioma;  but  in  the  cord  the 
line  of  least  resistance  is  up  and  down,  and  the  gliomatous  tissue  forms  a 
rod  along  the  centre  of  the  cord.  Neuroglia  tumors  tend  to  break  down 
centrally.  Glioma  of  the  brain  is  thus  commonly  cystic,  and  gliosis  of  the 
cord  when  advanced  is  characterized  by  cavity  formation  within  it,  by 
which  the  cord  is  finally  converted  into  a  tube.  From  this  circumstance 
the  entire  disease-process  gets  its  name  syringomyelia. 

Dissociated  anaesthesia  may  result  from  tumor,  hemorrhage  in  the  cen- 
tral gray  matter,  but  it  is  so  early  and  so  constant  in  gliomatosis  that  it 
is  commonly  spoken  of  as  syringomyelic  dissociation. 

As  the  neuroglia  mass  spreads  it  causes  various  symptoms,  most  com- 
monly those  of  progressive  muscular  atrophy  because  the  ventral  gray 


EXAMINATION  OF  THE  NERVOUS  SYSTEM.  359 

horns  are  slowly  invaded.  In  chronic  poliomyelitis  it  is  usually  the  hands 
and  arms  that  are  atrophied,  the  cervical  and  upper  thoracic  part  of 
the  cord  being  the  commonest  seat  of  the  gliosis.  The  pain  and  tem- 
perature fibres  from  each  root-zone,  having  reached  the  opposite  margin 
of  the  cord,  turn  upward  to  form  the  column  of  Gowers.  This  column 
is  bounded  in  front  by  the  motor  root-zone,  behind  by  an  imaginary 
line  passing  transversely  through  the  central  canal.  A  lesion  such  as 
tumor  severing  the  column  of  Gowers  will  cause  dissociated  anaesthesia 
below  it  on  the  opposite  side  of  the  body.  Lateral  trauma  of  the  spine 
is  likely  to  sever  this  column,  with  a  similar  result;  but  practically 
suoh  a  trauma  always  implicates  also  the  crossed  pyramidal  tract,  causing 
motor  paralysis  on  the  side  of  the  lesion.  The  combination  of  motor  paral- 
ysis on  one  side  of  the  body  and  sensory  paralysis  on  the  opposite  side, 
"  Brown-Sequard's  paralysis,"  is  pathognomonic  of  unilateral  cord  lesion. 
In  Brown-Sequard's  paralysis  touch  sense  is  usually  preserved  on  both 
sides  of  the  body,  the  dorsal  columns  of  the  cord  escaping. 

10.   Muscular  Sense. 

Normal  coordination  depends  upon  several  factors,  any  one  of  whicn 
being  defective,  incoordination  or  ataxia  may  result.  In  walking,  under 
normal  circumstances,  the  sensations  imparted  by  the  surface  control  to 
some  extent  the  movements,  and  the  absence  of  this  control,  as  in  the 
anaesthesia  of  tabes,  constitutes  an  element  of  ataxia.  Subconscious  sensa- 
tions from  the  joints,  muscles,  skin,  fasciae,  together  with  appreciations 
of  weight  and  balance,  enter  into  the  special  kind  of  perception  designated 
the  muscular  sense — "sixth  sense"  of  Sir  Charles  Bell — and  defect  of  this 
sense  is  an  important  factor  in  most  forms  of  ataxia.  It  is  suppressed 
at  its  very  source  when  the  nerve-termini  in  joints  and  muscles  are  impli- 
cated in  a  peripheral  neuritis,  and  this  causes  so  marked  an  ataxia  that 
such  cases  have  been  designated  peripheral  pseudotabes.  A  part  of  the 
ataxia  in  such  cases  of  peripheral  neuritis  may  be  due  to  anaesthesia  of 
the  skin.  The  ataxia  of  true  tabes  has,  to  some  extent,  this  same  periph- 
eral origin,  since  neuritis  is  a  part  of  the  disease,  but  it  has  a  more 
important  spinal  origin.  In  the  cord  many  muscular-sense  axons  pass 
up  the  dorsal  columns  in  company  with  the  touch-sense  axons,  and  here 
they  are  implicated  in  tabetic  degeneration.  Ataxia,  by  loss  of  muscular 
sense  and  by  anaesthesia  combined,  is  a  constant  symptom  of  lesion  of 
the  dorsal  columns. 

Muscular  sense  is  represented  in  the  cerebral  cortex  posterior  to  the 
motor  area,  being  associated  with  touch  sense  hero  as  in  the  cord.  These 
two  senses  are  involved  when  the  hand,  unaided,  recognizes  an  object  held 
in  it  (stereognosis) ;  they  are  especially  combined  for  this  purpose  in  the 
superior  parietal  lobule,  and  loss  of  this  perceptive  power — astcrcognosis — 
is  most  commonly  due  to  lesion  in  that  area. 

.Muscular  sense  guides  the  cerebellum  in  its  chief  function,  the  mainte- 
nance of  equilibrium.  Fibres  delegated  to  this  function  from  the  root- 
zone  enter  the  base  of  the  dorsal  gray  horn  and  connect  with  the  cell- 
bodies  of  Clarke  and  Stilling  which  arc  found  in  that  situation  throughout 


360  MEDICAL  DIAGNOSIS. 

the  cord  (Gordinier).  These  cell-bodies  are  the  beginning  of  superior 
muscular-sense  neurons;  their  axons  sweep  outward  to  the  margin  of  the 
cord  and  turn  upward  in  the  direct  cerebellar  tract,  the  terminus  of 
which  is  the  middle  lobe — vermis — of  the  cerebellum,  which  it  reaches 
by  way  of  the  inferior  cerebellar  peduncle — restiform  body.  Lesion  of 
this  neuron-system,  in  the  cord  or  in  the  cerebellum  (Barker),  causes  the 
defect  of  equilibration  called  cerebellar  ataxia. 

Assistance  in  coordination  is  derived  from  all  the  senses,  consciously, 
as  when  the  tabetic  watches  the  ground  in  walking,  and  unconsciously, 
through  impulses  collected  in  the  cerebellum  from  the  eye,  cutaneous  sen- 
sations, the  joint  and  muscle  surfaces  and  the  internal  ear.  Disturbance 
in  one  of  these  sensory  organs  may  cause  vertigo. 

The  internal  ear  is  virtually  two  organs,  having  distinct  functions, 
and  the  eighth  nerve  is  double  accordingly.  The  semicircular  canals  of  the 
vestibule  are  water-levels  telling  the  position  of  the  head,  as  muscular 
sense  does  that  of  the  limbs,  and  the  part  of  the  eighth  nerve  arising  thence 
called  the  vestibular  nerve  is  concerned  not  with  hearing  but  with  equili- 
bration. It  connects  with  its  superior  neurons  in  the  dorsomesal  nucleus 
to  pass  to  the  cerebellum. 

Lesion  of  any  part  of  the  vestibular  tract  from  the  internal  ear  to  the 
cerebellum  may  cause  vertigo,  as  in  Meniere's  disease. 

The  eighth  nerve's  division  into  two  is  clear  as  it  enters  the  pons,  the 
two  parts  being  separated  by  the  inferior  cerebellar  peduncle.  The  outer  or 
cochlear  division  is  the  true  nerve  of  hearing.  It  enters  the  ventrolateral 
nucleus  to  be  continued  by  fibres  that  cross  the  middle  line  of  the  pons, 
forming  the  trapezoid  body, — acoustic  decussation  (M.  Allen  Starr), — then 
pass  upward  in  the  lateral  fillet,  and  by  way  of  the  postgeminum  and  post- 
geniculum  reach   the  auditory  centre  in  the  first  temporal  convolution. 

The  Stigmata  of  Degeneration. 

Degeneration,  degeneracy,  deviation  are  terms  used  to  denote  in 
individuals  a  decline  from  the  average  normal  condition  in  physical  or 
moral  qualities.  This  decline  varies  in  degree  from  deviations  from  the 
normal  scarcely  to  be  recognized  upon  the  most  careful  study,  to  the  pos- 
session of  physical  and  moral  defects  which  render  the  subject  unfit  for 
the  ordinary  duties  and  responsibilities  of  life,  and  are  obvious  to  the  casual 
observer.  It  is  accompanied  by  physical,  physiological  and  neuropsychic 
anomalies  known  as  the  "stigmata  of  degeneration."  An  undue  impor- 
tance has  doubtless  been  ascribed  to  these  anomalies  and  their  combina- 
tions, especially  to  those  of  minor  degree,  by  Lombroso  and  his  followers; 
nevertheless  their  consideration  is  of  practical  value  in  the  study  of  diseases 
of  the  nervous  system  and  has  an  important  bearing  upon  the  diagnosis 
and  prognosis  of  individual  cases  of  this  group  of  affections.  Every  sign 
of  deviation  from  the  average  normal  is  not  necessarily  a  stigma  of  degen- 
eration, and  Walton  has  suggested  that  it  is  desirable  "  to  name  the  phe- 
nomena signs  of  deviation,  and  call  their  possessors  deviates  or  a  deviate 
as  the  case  may  be,  limiting  the  term  degeneration  only  to  such  deviations 
as  obviously  imply  deterioration." 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 


361 


Etiological  Classification. — "Walton  has  grouped  the  causes  of  the 
so-called  stigmata  of  degeneration,  including  the  signs  of  deviation  only, 
as  follows: 

I.  The  potential  variations  from  the  average  normal  contained  in  the 
parent  germ,  including  the  results  (a)  of  atavism,  (b)  of  parental  similarity, 
and  (c)  of  selective  tendency  on  the  part  of  the  ancestry. 

II.  Intra-uterine  infection. 

III.  Mechanical  injury  during  intra-uterine  life. 

IV.  The  absence  or  peculiarity  in  the  germ  of  certain  elements,  or 
their  disappearance  or  anomalous  development,  without  traceable  inherited 
tendency  or  other  known  explanation. 

V.  Mechanical  influence  exerted  during  infancy. 

VI.  Deleterious  influences  and  habits  in  the  ancestry,  productive  of 
enfeeblement,  undersize,  and  lessened  resistance  in  the  progeny  but  not  alter- 
ing the  essential  potential  characteristics  transmitted  by  the  parent  germ. 

VII.  Absence  or  hypertrophy  of  certain  glands,  pituitary,  thyroid, 
which  have  a  nutritional  influence. 

VIII.  Arrest  of  development,  such  as  is  seen  in  harelip  and  similar 
defects. 

List  of  Stigmata. — The  following  list,  compiled  from  Dana,  Church 
and  Peterson,  Walton,  and  others,  includes  the  more  important  deviations 
and  stigmata.  Those  which  are  of  minor  significance,  either  alone  or  in 
association  with  others,  as  indicating  actual  degeneracy,  are  placed  in 
middle  single  columns;  those  generally  recognized  as  stigmata  of  degen- 
eration, in  double  columns  at  the  sides. 


Anatomical  Stigmata. 

Anomalies  of  the  Cranium. 


Cranial  asymmetry. 

Macrocephalus. 

Microcephalus. 

Platycephalus. 

Leptocephalus. 

Oxycephalic 

Plagiocephalus. 

Scaphocephaly. 

Trigonocephalus. 

Short  parietal  arc. 

Short  frontal  arc. 

High  prominent  forehead. 

Anomalies  of  the  Face. 


Heavy  jaws. 

Prognathism. 

Lemurian  hypophysis. 

Opisthognathism  or  retrogna- 

Orthognathism. 

thism. 

Large   frontal    sinuses,   small 

Crania  progenia  (lower  teeth 

orbit. 

projecting   beyond    upper, 

Great  or  unequal  prominence 

and  interior  maxillary  angle 

of  malar  bones. 

obtuse). 

Anomalies  of  the  Ete. 


Narrow  palpebral  fissure. 

Flecks  on  the  iris. 

Microphthalmos. 

Albinism. 

Chromatic  asymmetry  of  the 

iris. 

Congenital  cataracts. 

Pigmentary  retinitis. 

Myopia. 

Hypermetropia. 

Muscular   insufficiency,  stra- 
bismus. 
Astigmatism. 

362 


MEDICAL  DIAGNOSIS. 


Deformities  of  the  Palate. 


High  and  narrow. 
Torus  palatinus. 
Dome-shaped. 
Hip- roofed. 


Horseshoe. 
Gothic  arch. 
Flat- roofed. 
Asymmetrical. 


Dental  Anomalies. 


Badly  set   and 

badly 

nour- 

Small  or  peg-shaped   lateral 

ished. 

Double  rows. 
Adventitious  teeth. 
Double  crown. 
Macrodontism. 

incisors. 

Microdontism. 

Projecting  teeth. 

Badly  placed 

sr    mis 

placed 

Striated  transversely. 

teeth. 

Hutchinson's  teeth. 

Anomalies  of  the  Nose. 


Defective  development  of 
cartilage  and  tissue  of  alse. 


Deviation  of  nose. 


Absent  cartilages. 
Atresia  of  nasal  fossa. 


Defective 
ment. 


osseous    develop- 


Anomalies  of  the  Tongue  and  Lips. 


Macroglossus. 
Microglossus. 
Bifidity  of  point. 
Harelip. 
Cleft  palate. 


Anomalies  of  the  Ear. 


Excessively  long. 

Excessively  prominent. 

Set  too  close  to  the  head. 

Set  too  far  back. 

Set  too  low. 

Absence  of  helix,  antihelix,  or 

Obliteration  of  markings. 

lobule. 

Absence  of  fissura  intertrag- 

Too  conchoidal  (antihelix, 

lca. 

Excessively  large  (absolutely 

crura,  etc.,  too  little  marked 

'     or  relatively). 

and  helix  like  rim  of  funnel) . 

Too  small. 

Lack  of  uniformity  in  width. 

Asymmetry  of  the  two  ears, 

general    anomaly   of  left 

(Blainville  ear). 

Prominence  of  antihelix. 

Adherent  lobules. 

Anomalies  of  the  Limbs. 


Symphysodactyly  or  achisto- 
dactylus  (joining  of  fin- 
gers). 

Ectrodactyly  (fingers  want- 
ing). 


Left  arm  and  leg  longer  than 

right. 
Excessive  length  of  arms. 
Long  fingers. 
Polydactyly. 


Syndactyly  (web  fingers). 


Amelus   or    ecromelus    (limb 
wanting) . 


EXAMINATION  OF  THE  NERVOUS  SYSTEM. 
Anomalies  of  the  Limbs. 


363 


Phocomelus  (segment  of  limb 
wanting). 

Oligomelus  (excessive  gracil- 
ity). 

Megalomelus. 
Megalodactyly. 

Oligodactyly. 

Anomalies  of 

the  Trunk  and 

G 

eneral  Structure. 

Hernias,  when  congenital. 

Malformation  of  breasts  and 
thorax. 

Dwarfism. 

Gigantism. 

Infantilism. 

Masculinism  in  women. 

Spina  bifida. 

Femininism  in  men. 

Feebleness  of  construction. 

Lordosis. 

Scoliosis. 

Kyphosis  (Fere). 

Malformed  coccyx. 

Thoracic  asymmetry. 

Mammary   development   in 

Mammary  absence   or   redu- 

males. 

plication  in  females  (poly- 
mastia). 

Anomalies  of  the  Genital  Organs. 

Small  or  deformed  genitalia. 

Hermaphrodism. 

Crypto  rchismus. 

Hypospadias. 

Epispadias. 

Defect,   or  great   volume  of 
prepuce. 

Torsion  of  prepuce. 

Imperforate  meatus. 

Labia  too  large  or  too  small. 

Clitoris  large. 

Labia  minora  hypertrophied. 

Folds  between  labia  majora 
and  minora. 

Labia  minora  pigmented,  par- 
ticularly in  brunettes. 

Imperforate  vulva. 

Atresia  of  vagina. 

Double  vagina. 

Uterus  bicornis. 

Atrophic  uterus. 

Muscular  Anomalies. 


Dystrophies. 

Depression  above  glabella  due 
to  overaction  of  corrugators. 


Unequal  innervation  of  facial 
muscles  on  the  two  sides. 


Anomalies  of  the  Skin. 


Polysarcia. 

Hypertrichosis      (superfluous 

hair). 
Premature  grayness. 

Precocious  and    abnormal 

hairy  development. 
Rudimentary  tail. 

Glabrous  chin  (no  beard). 
Absence  of  nails  or  fetal  state 

Vitiligo. 
Melanism  of  skin. 

of  nails. 

Pigmented  or  vascular  nam. 

Molluscum. 

Pigmented  spots. 

Irln  hyosis. 

364 


MEDICAL  DIAGNOSIS. 
Physiological  Stigmata. 

Anomalies  of  Motor  Function. 


Lefthandedness. 
Retardation    of    learning    to 

walk  and  talk. 
Nystagmus  (congenital). 


Tremors. 
Epilepsy. 

Tics. —  Facial    spasm,    habit 
chorea,  tic  convulsif. 


Anomalies  of  Sensory  Function. 


Deaf-mutism. 


Hyperesthesia. 
Blindness. 


Nyctalopia  (day-blindness). 


Neuralgia. 

Migraine. 

Constitutional  headaches. 


Daltonism    (color  -  blindness, 

achromatopsia) . 
Hemeralopia     ( night  -  blind- 


ness) . 


Anaesthesia. 


Concentric  limitation  of  visual 
field. 


Anomalies  of  Speech. 

Mutism. 

Stammering. 
Stuttering. 

Defective  speech. 

Anomalies  of  Genito-urinary  Function. 

Sexual  irritability. 

Sterility. 

Amenorrhoea. 

Impotence. 

Urinary  incontinence. 

Anomalies  of  Instinct  or  Appetite. 

Gluttony. 
Rumination. 

Merycism. 

Uncontrollable  appetites  (nar- 
cotics). 

Retardation  of  Puberty. 

Deficient  Vital  Activity  of  Organic  Functions. 

Weak  heart. 

Low  arterial  tension. 

Coldness  of  extremities. 

Flushing  of  extremities. 

General  chills  and  flushes. 

Weak  digestion. 

Constipation. 


Psychic  and   Psychoneurotic  Stigmata. 


Dementia  prsecox. 
Mania  depressive. 

Compulsive  insanity. 
Melancholia. 

Hysteria. 
Phobia. 
Invalid  habit. 
Feeble-mindedness. 

Hypochondria. 
Psychopathic  endowment. 
Idiocy. 

Moral  delinquency, 
Precocity. 

Paranoia. 

Eccentricity. 

Sexual  perversion. 
Over-development  of  certain 

aptitudes. 
Ideo-obsessive  constitution. 

EXAMINATION  OF  THE  EYE. 


365 


X. 
THE  EXAMINATION  OF  THE  EYE.1 


General  Considerations. 

The  close  relationship  existing  between  the  eye  and  the  nervous 
system,  the  opportunities  furnished  by  the  fundus  of  the  eye  to  study 
changes  in  the  general  circulatory  system,  and  the  knowledge  that  disturb- 
ances of  ocular  function  are  not  infrequently  the  underlying  cause  of 
systemic  affections,  render  a  study  of  the  ocular  apparatus  of  extreme 
importance  in  the  diagnosis  of  general  disease. 

It  must  be  remembered  that,  while  the  eye  is  the  organ  of  sight,  with 
its  own  special  function,  it  is  also  a  part  of  the  general  organism,  is  influ- 
enced by  the  status  of  the  whole  body,  is  disturbed  with  the  disturbance 
of  other  structures,  and  exhibits  in  a  marked  degree  affections  of  other 
organs  by  which  its  function  is  interfered  with. 

The  importance  of  the  thorough  analysis  of  the  ocular  complications  in 
all  diseases,  particularly  in  affections  of  the  brain  and  spinal  cord,  is  well  rec- 
ognized. An  examination  of  this  character,  to  be  effective,  must  be  systema- 
tized in  order  to  determine  the  actual  conditions  underlying  an  affection  of 
which  the  eyes  furnish  the  chief  manifestation;  in  what  respect,  if  any,  the 
ocular  functions  are  abnormal;  and  finally,  the  true  inference  to  be  drawn 
from  these  disturbed  functions  in  the  diagnosis  of  systemic  affections. 

1.  Inspection:  The  position  of  the  eyeballs  in  relation  to  the  orbital 
bones  is  observed  to  determine  any  undue  prominence  or  recession  of  one 
or  of  both  eyes;  any  abnormality  of  the  eyelids  as  evidenced  by  tumors, 
general  swelling,  drooping,  inability  to  close  the  lids,  inverted  margins, 
size  of  the  commissure,  and  the  presence  of  crusts  or  secretions  on  the 
margins;  congestion  of  the  blood-vessels,  or  granulations  or  new  growths 
on  the  conjunctiva;  the  size,  response  to  light  stimuli,  and  equality  or 
inequality  of  the  pupils,  and  variations  in  the  color  of  the  irides;  deviation 
of  the  visual  axes,  or  involuntary 
movement  of  the  eyeballs;  the  sensi- 
bility of  the  cornea  or  its  loss  of 
transparency;  and  the  depth  of  the 
anterior  chamber  and  any  turbidity 
of  its  fluid  contents. 

The  anterior  segment  of  the 
eyeball  is  most  satisfactorily  studied 
by  oblique  illumination.  The  patient 
is  placed  about  two  feet  from  the 
source  of  illumination.  The  exam- 
iner focusses  the  light  upon  the 
cornea  with  a  convex  lens  of  2-inch  or  3-inch  focus  held  botwoon  the  thumb 
and  forefinger  of  the  right  hand,  and  studies  the  illuminated  area  through 
another  lens  of  similar  strength  held  between  the  thumb  and  forefinger  of  the 

1  Contributed  by  Professor  Sweet  as  collaborator. 


Fig.    147. — Oblique  or    focal    illumination, 
llansell    and    Sweet. 


-From 


366 


MEDICAL  DIAGNOSIS. 


left  hand,  the  second  finger  raises  the  upper  lid,  and  the  little  finger  resting 
upon  the  forehead  steadies  the  hand.  The  distance  of  the  second  lens  from 
the  eye  is  varied  slightly  to  bring  into  focus  the  cornea,  iris,  and  crystalline 
lens.  Opacities  of  the  cornea  or  lens,  as  seen  by  oblique  illumination, 
appear  as  gray  or  white  spots  upon  the  black  background  of  the  pupil. 

2.  Vision:  Decrease  in  the  normal  acuteness  of  vision  of  each  eye 
as  measured  by  test  letters  for  near  and  far  is  to  be  noted;  the  history  of 
the  decline,  and  its  association  with  pain  or  inflammation  of  the  external 
structures;  any  departure  from  the  normal  field  of  vision  must  be  recorded; 
contraction  of  the  peripheral  limits  for  form  and  color,  areas  of  deficient  or 
lost  perception,  and  reversal  in  the  order  of  the  color  fields. 

3.  Ophthalmoscopic  Examination:  Two  methods  are  employed  in 
the  examination  of  the  deeper  structures  of  the  eye  by  the  ophthalmo- 
scope— the  Direct  Method,  which  gives  an  upright  image  of  the  eyeground, 

and  the  Indirect,  in  which  the  image 
is  inverted.  In  both  the  patient  is 
seated  in  a  darkened  room  with  his 
back  to  the  source  of  illumination, 
and  the  observer  is  to  the  side  to 
be  examined.  By  the  direct  method 
the  examiner  approaches  close  to  the 
side  of  the  patient's  head,  using  his 
eye  corresponding  to  the  eye  under 
examination,  and  reflects  the  light 
by  means  of  the  ophthalmoscopic 
mirror  into  the  eye.  The  rays  from 
the  fundus  are  reflected  back,  and, 
passing  through  the  opening  in  the 
mirror  enter  the  observer's  eye,  giv- 
ing an  upright  image  of  the  eyeground.  The  optic  nerve  is  best  seen 
when  the  patient  looks  at  a  distant  object  to  the  side  and  beyond  t^e 
observer's  head.  The  foveal  region  is  brought  into  view  when  the  patient's 
gaze  is  directed  into  the  aperture  of  the  mirror.  By  the  indirect  method 
the  observer,  about  15  to  20  inches  in  front  and  to  the  side  of  the  patient, 
reflects  the  light  through  a  convex  lens  of  about  2-inch  focus  held  at 
its  focal  length  from  the  eye,  and  secures  an  aerial  image  focussed  by 
the  strong  glass.  In  case  the  details  of  the  fundus  are  not  at  first  plainly 
seen  the  object  lens  is  slightly  advanced  or  withdrawn  from  the  eye. 
Strain  on  the  examiner's  accommodation  is  relieved  by  a  +4  D.  lens 
rotated  before  the  sight-hole  of  the  ophthalmoscope. 

The  normal  eye  presents  many  variations  from  the  typically  pictured 
fundus,  and  extended  experience  is  necessary  to  distinguish  the  variations  in 
health  from  the  changes  wrought  by  disease.  The  color  of  the  fundus  reflex  is 
a  bright  pink  or  red,  due  to  the  reflected  light  from  the  choroidal  vessels  and 
the  pigment  of  the  retina  and  choroid.  In  the  negro  the  reflex  is  grayish,  be- 
cause of  the  absorption  of  the  light  rays  by  the  abundant  pigment.  The  optic 
disk,  or  nerve  head,  lies  to  the  nasal  side  of  the  posterior  pole,  and  is  round  or 
oval,  with  clear  cut  edges,  often  fringed  with  choroidal  pigment.  The  nerve 
is  often  cupped  in  the  centre,  at  which  point  the  central  artery  and  vein 


Fig.  148. — Ophthalmoscopic  examination  by  direct 
method.— From  Hansell  and  Sweet. 


PLATE  VIII. 


c  D 

[Varieties  of  the  Normal  Fundus. — After  Wiirdemann  in  Posey  and  Spiller. 

A,  albinotic  fundus;  albino  and  light  blonde  (after  Greef,  modified  by  Wurdemann).  B,  the 
tessellated  fundus;  brunette  (after  Greef,  modified  by  Wurdemann).  C,  the  negroid  fundus;  negro 
(Wurdemann).     D,  the  yellowjundus;  Chinese  (after  Oeller,  modified  by  Wurdemann). — D.J 


EXAMINATION  OF  THE  EYE.  367 

pass.  The  artery  and  vein  divide  into  two  main  branches,  and  these  sub- 
divide into  the  numerous  smaller  vessels.  The  fovea,  with  its  central 
yellow  spot,  is  the  most  sensitive  part  of  the  retina.  It  is  about  3  mm. 
to  the  temporal  side  of  the  nerve,  and  is  darker  than  the  rest  of  the  retina. 
In  this  region  no  blood-vessels  are  to  be  seen  by  the  ophthalmoscope. 

4.  Pain:  The  character  of  the  pain  should  be  known,  its  situation,  its 
dependence  on  the  use  of  the  eyes,  and  its  association  with  tenderness  in 
the  region  of  the  orbit,  particularly  at  the  points  of  exit  of  the  supra-orbital 
or  infra-orbital  nerves. 

5.  Headache  is  one  of  the  most  prominent  symptoms  of  eyestrain.  It 
is  dull  and  heavy,  usually  bilateral,  increased  by  application  to  close  work, 
riding  in  cars  and  shopping,  and  sometimes  accompanied  by  pain  in  the  eye- 
balls. It  is  to  be  distinguished  from  the  sharp  periodic  attacks  of  pain 
characteristic  of  neuralgia  of  the  first  and  second  divisions  of  the  5th  nerve. 

Affections    of    the    nasal  tissues,  as   deflections   of    the   septum  and 
purulent   collections   in   the  frontal  sinus,  cause  headache  which  resem- 
bles that  of  eyestrain.     The  diag- 
nosis of  nasal  and  sinus  headache 
is  made  by  its  longer  duration,  its 
association  with  manifest  symptoms 
of  nasal  trouble,  and  its  independ- 
ence of  use  of  the  eyes. 

Asthenopia  from  general 
muscle  weakness  is  present  during 
convalescence  from  acute  fevers  or 
prolonged  illnesses,  and  attempts  at 

]•  r,         f   ii    „      ]i        i  „„  l  Fig.  149. — Ophthalmoscopic  examination  bv  indirect 

reading  are  often  followed  by  head-  method.— From  Hansen  and  Sweet. 

ache,  blurring  of  sight,  and  pain  in 

the  eyes  and  head.  DeSchweinitz  refers  to  a  peculiar  form  of  asthenopia  seen 
after  the  presbyopic  age,  most  frequently  in  women,  which  is  not  relieved 
by  glasses  or  treatment  of  muscular  anomalies.  These  patients  present 
the  ordinary  symptoms  of  neurasthenia,  doubtless  the  outcome  of  begin- 
ning arteriosclerosis,  and  proper  tests  usually  show  high  arterial  tension, 
which,  if  reduced  by  appropriate  dietetic  and  medicinal  measures,  will 
cause   a   disappearance  of  the  asthenopia. 

6.  Photophobia  is  a  symptom  of  affections  of  the  cornea  and  iris, 
of  a  few  diseases  of  the  retina,  and  in  many  cases  of  uncorrected  refractive 
errors  and  muscular  anomalies.  As  an  isolated  symptom  it  possesses 
little  importance  in  arriving  at  a  differential  diagnosis  of  ocular  affections. 

7.  Epiphora:  Increase  in  the  flow  of  tears  is  seen  in  exophthalmic 
goitre,  in  certain  affections  of  the  central  nervous  system  (locomotor 
ataxia),  and  in  obstruction  of  the  lachrymal  duct. 

The  Eyeball  and  Orbit. 

Protrusion  of  the  eyeball—  exophthalmos,  proptosis — may  be  caused 
by  tumors,  aneurisms,  hemorrhage,  exostoses,  or  inflammations  originating 
in  or  extending  to  the  orbit  from  the  adjacent  sinuses;  by  orbital  cellulitis, 
sinus  thrombosis,  and  paralysis  of  the  ocular  muscles. 


368  MEDICAL  DIAGNOSIS. 

Bilateral  exophthalmos,  varying  from  a  slight  prominence  of  the 
eyeballs  to  a  protrusion  that  prevents  the  closure  of  the  eyelids  with  no 
inflammatory  signs,  is  found  in  exophthalmic  goitre.  Widening  of  the 
palpebral  fissure  from  nervous  affections,  and  from  the  instillation  of 
cocaine,  with  undue  exposure  of  the  sclera,  will  give  the  impression  of 
exophthalmos. 

Proptosis  associated  with  deep-seated  pain  upon  attempts  to  move  the 
eyeball,  limited  or  complete  immobility  of  the  globe,  and  swelling  and  oedema 
of  the  eyelids,  which  may  be  so  great  as  to  prevent  opening  of  the  lids, 
occurs  in  thrombosis  of  the  cavernous  sinus.  Inflammations  in  the  orbit, 
facial  erysipelas,  with  infection  carried  to  the  sinus  by  the  facial  and 
ophthalmic  veins,  infective  inflammation  of  the  tonsils,  nasal  cavities  and 
accessory  sinuses  may  be  causative  factors.  The  symptoms  are  gradual  in 
their  development,  affecting  at  first  one  eye,  later  the  other.  Inflammatory 
exophthalmos  is  also  found  in  orbital  cellulitis  due  to  growths  or  infection 
from  adjacent  sinuses,  and  rarely  after  scarlet  fever,  typhoid  fever,  and 
influenza. 

Sudden  exophthalmos  in  infants,  with  the  eyeballs  turned  down,  may  be 
due  to  scurvy.  The  protrusion  may  be  moderate  at  first  and  increase  during 
24  hours  and  be  associated  at  its  height  with  thickening  and  ecchymosis  of 
the  upper  lid.  The  subperiosteal  hemorrhage  to  which  the  affection  is 
due  may  affect  both  orbits,  but  unequally.     The  eyeball  is  freely  movable. 

Pulsating  exophthalmos,  usually  unilateral,  most  frequently  follows 
traumatism,  and  is  found  in  arteriovenous  aneurism  of  the  internal  carotid 
and  cavernous  sinus  or  aneurism  of  the  ophthalmic  artery. 

Abscess  of  the  frontal  sinus  may  cause  displacement  of  the  eyeball 
downwards  and  outwards,  with  diplopia.  In  purulent  disease  of  the  frontal 
and  ethmoidal  sinuses  a  small  fluctuating  swelling  may  appear  at  the  upper 
and  inner  angle  of  the  orbit,  which  breaks  and  discharges  pus.  Gradual 
displacement  of  the  eyeball  forward  may  be  the  result  of  an  orbital  tumor 
within  the  cone  of  muscles. 

Exophthalmic  Goitre. — One  of  the  earlier  signs  is  lagging  of  the  upper 
lid  when  the  eyes  are  slowly  rotated  downwards  (Graefe's  sign).  There  is 
also  imperfect  power  of  winking  (Stellwag's  sign)  ;  retraction  of  the  upper 
lid  and  widening  of  the  palpebral  fissure  (Dalrymple's  sign),  and  imperfect 
power  of  convergence  of  the  eyes. 

Involuntary  resistance  to  eversion  of  the  upper  eyelids  may  be  one  of 
the  earliest  symptoms  of  Graves's  disease.  It  tends  to  disappear  with  the 
development  of  the  disease,  and  is  explained  by  hyperexcitability  of  Muller's 
muscle  through  the  sympathetic.  Swelling  of  the  tissues  between  the  eyebrow 
and  eyelid  is  an  early  diagnostic  sign  of  the  disease. 

Retraction  of  Eyeball. — Enophthalmus,  or  sinking  of  the  eye  into  the 
orbit,  occurs  in  some  instances  in  extreme  emaciation  from  absorption  of 
orbital  fat,  in  paralysis  of  the  sympathetic,  in  facial  hemiatrophy,  and 
from  traumatism.  Traumatism  in  the  vicinity  of  the  orbit  is  sometimes 
followed  by  an  actual  enophthalmus,  which  may  be  immediate,  or  be  delayed 
for  several  weeks  or  months. 

Nystagmus  is  a  series  of  involuntary,  regular,  and  rapid  oscillations 
of  the  eyes.     These  movements  may  be  horizontal,  vertical,  or  rotary,  or 


EXAMINATION  OF  THE  EYE.  369 

a  combination  of  all  three.  Unilateral  nystagmus  is  rare.  The  lateral  oscil- 
lation is  the  most  common.  Congenital  nystagmus  is  found  in  children  with. 
congenital  cataract,  dense  central  corneal  opacity,  or  imperfectly  developed 
eyeballs,  central  choroiditis,  and  in  albinism.  Miner's  nystagmus  is  an 
acquired  form,  probably  due  to  the  prolonged  upward  inclination  of  the 
eyes  in  semi-darkness.  Nystagmus  may  be  a  symptom  of  irritation  or 
diseases  of  the  inner  ear,  of  tumors  of  the  cerebellum,  multiple  sclerosis, 
hereditary  ataxia,  and  of  syringomyelia. 

In  multiple  sclerosis  and  in  hereditary  ataxia  nystagmus  occurs  only 
when  the  eyes  are  turned  in  the  direction  of  a  moving  object,  and  particularly 
as  the  eyes  reach  the  limit  of  their  rotation  in  the  lateral  plane.  A  slight 
nystagmus  is  occasionally  found  in  hysteria. 

Tension. — In  the  normal  eyeball  the  tension  of  the  globe,  as  measured 
by  the  pressure  of  the  two  index  fingers  upon  the  sclera  through  the  closed 
lid,  presents  a  uniform  resistance.  Increase  in  the  intra-ocular  tension 
occurs  in  acute  glaucoma,  in  some  forms  of  iridocyclitis,  irritation  of  the 
cervical  sympathetic,  intra-ocular  tumors,  and  occasionally  after  traumatism. 
Lowered  tension  may  result  from  degeneration  of  the  ciliary  body  and 
choroid,  rupture  of  the  globe,  detachment  of  the  retina,  diabetic  coma,  and 
after  operations. 

The  Eyelids. 

Marginal  Inflammation. — Red  and  swollen  lid  margins,  associated  with 
heat,  burning  and  photophobia,  are  seen  in  persons  exposed  to  cold  winds  and 
dust,  in  children  affected  with  nasopharyngeal  inflammation  following 
measles,  and  as  a  result  of  the  strain  of  uncorrected  refractive  errors.  In 
severe  types  of  the  disease  the  lid  margins  are  covered  writh  crusts  which, 
upon  removal,  expose  ulcers  extending  deep  into  the  border. 

Redness  and  itching  of  the  lid  margins  in  children  may  be  due  to  the 
presence  of  the  pediculus  pubis  in  the  eyelashes.  Close  examination  will 
show  the  eggs  upon  the  cilia,  and  the  parasite  partly  buried  in  the  hair 
follicle. 

Inversion  of  the  lashes  or  of  the  lid  border  is  most  commonly  caused 
by  chronic  inflammation  of  the  palpebral  conjunctiva.  The  irritation  of  the 
cilia  leads  to  inflammation  and  haziness  of  the  cornea.  Eversion  of  the  lid 
may  follow  burns  or  wounds,  with  subsequent  cicatricial  contraction  of  the 
skin:  appears  as  a  senile  condition,  from  loss  of  muscle  power;  or  accom- 
panies facial  palsy.     The  lower  lid  is  most  frequently  affected. 

(Edema  of  the  lids  accompanies  severe  inflammation  of  the  conjunctiva, 
purulent  disease  of  the  eyeball  or  orbit,  infection  of  the  cavernous,  frontal 
or  ethmoidal  sinuses,  and  in  general  affections  like  nephritis  and  gout. 

Localized  swelling  of  the  eyelids  and  conjunctiva,  with  or  without 
vascular  changes  of  the  eyeball,  is  seen  in  neurotic  urfcma,  urticaria,  and 
disease  of  the  antrum,  or  may  be  due  to  errors  <>i'  diet.  The  swelling  may 
be  sufficient  to  completely  close  the  eye.  ami  is  accompanied  by  itching 
and  burning.    In  a  few  days  the  parts  return  to  the  normal. 

A  localized  painful  swelling  of  the  lid  and  discoloration  of  the  skin 
may  1»"  either  a  stye  {hordeolum  l  or  an  ahseess  of  the  lid  {phlegmon).  The 
pain  is  severe  and  is  frequently  accompanied  by  swelling  of  the  entire  lid 


370  MEDICAL  DIAGNOSIS. 

and  oedema  of  the  conjunctiva.  Styes  are  situated  in  the  connective  tissue 
near  the  lid  margin  and  are  apt  to  recur  in  persons  with  deranged  bodily 
functions,  and  in  those  who  suffer  from  uncorrected  refractive  errors. 

Swelling  of  the  lid,  appearing  suddenly  after  injury,  and  increasing 
upon  blowing  the  nose,  the  soft  mass  crackling  on  pressure,  is  caused  by 
the  presence  of  air  which  has  escaped  into  the  cellular  tissue  through  a 
fracture  of  the  orbital  wall  (emphysema). 

Inflammation  of  the  tarsus  (tarsitis),  usually  monocular,  may  be  syphi- 
litic, gouty  or  tubercular.  The  lid  is  swollen  and  drooping  and  cannot  be 
raised  by  the  levator  palpebrarum  muscle. 

Sebaceous  cysts  occur  both  on  the  eyelids  and  in  the  eyebrow.  Accumu- 
lations of  sebum  appear  as  small  yellowish  elevations  which  develop  about 
the  age  of  puberty,  and  are  due  to  improper  care  of  the  skin  or  to  gastro- 
intestinal disorders.  Molluscum  contagiosum  is  a  disease  of  the  sebaceous 
glands  which  occurs  among  ill-nourished  children.  It  is  characterized  by 
waxy-colored,  rounded  papules,  the  size  of  a  pea. 

Erysipelas  attacks  the  lids  by  extension  from  the  adjoining  skin  of 
the  face.  The  shiny,  dusky  swelling,  with  subsequent  development  of 
small  vesicles,  serves  to  distinguish  it  from  other  affections.  Severe  attacks 
may  affect  the  orbital  tissues  and  cause  optic  nerve  atrophy  and  fatal 
meningitis. 

Syphilis. —  The  primary  lesion  most  frequently  occurs  at  the  lid  border, 
near  the  inner  canthus.  The  ulceration  and  induration  present  the  typical 
features  of  a  chancre.  It  may  be  mistaken  for  an  epithelioma,  but  the 
improvement  under  antisyphilitie  treatment  clears  up  the  diagnosis.  Tarsitis 
occurs  sometimes  in  the  secondary  stage. 

Herpes  Zoster. — Violent  paroxysmal  pain,  associated  with  a  vesicular 
eruption  on  the  skin  of  the  lid,  forehead  and  occasionally  the  side  of  the 
nose,  is  indicative  of  herpes  zoster  ophthalmicus.  The  vesicles  vary  in  size, 
have  an  inflamed  base,  and  are  situated  over  the  region  supplied  by  the 
first  and  second  division  of  the  fifth  nerve.  Corneal  ulcers,  iritis  and 
muscular  palsies  show  ocular  involvement.  Depressed  nutrition  is  a  common 
cause. 

Xanthelasma. — Yellowish  irregular  shaped  patches  of  connective  tissue, 
with  fatty  degeneration,-  located  in  the  upper  eyelids  near  the  internal 
canthus,  are  termed  xanthelasma.  Rarely  they  form  on  the  lower  lids.  The 
growth  is  probably  due  to  local  ill  nutrition. 

Chalazion. — A  small  round  elevation  of  either  the  upper  or  lower  lid, 
of  slow  growth,  with  the  skin  freely  movable  over  the  hardened  tumor,  and 
a  purplish  discoloration  of  the  surface  of  the  conjunctiva  immediately  be- 
neath, is  termed  a  chalazion.  It  is  due  to  inflammation  of  a  Meibomian  gland, 
with  retention  of  the  secretion.  Inflammation  of  the  lid  margins  and  the 
strain  of  ametropia  may  be  causative  factors. 

Inflammation  of  the  Lachrymal  Sac. — A  small  tumor  near  the  inner 
angle  of  the  lower  lid  over  the  lachrymal  sac,  which  disappears  upon  pres- 
sure, with  the  escape  of  a  viscid  mucus  through  the  puncta,  is  due  to  catarrhal 
inflammation  of  the  sac.  A  similar  condition  occurs  in  the  new-born  from 
congenital  atresia  of  the  lacrimonasal  duct.  Suppuration  with  severe  pain, 
and  intense  swelling  and  redness  of  the  skin  may  occur.    In  both  the  chronic 


EXAMINATION  OF  THE  EYE.  371 

and  acute  forms  the  tears  flow  over  the  cheek.  A  swelling  at  the  upper  and 
inner  angle  of  orbit,  due  to  sinus  disease,  may  be  mistaken  for  lachrymal 
abscess. 

Ptosis. — Drooping  of  the  eyelid,  partially  or  completely  covering  the 
cornea,  may  be  either  congenital,  or  due  to  injury  to  the  levator  muscle,  to 
thickening  of  the  tissues  of  the  lid,  to  paralysis  of  the  third  nerve,  or  to 
paralysis  of  the  sympathetic.  A  form  of  hysterical  ptosis  due  to  spasm  of 
the  orbicularis  muscle  has  been  described. 

Lagophthalmos,  or  inability  to  close  the  eyelid,  may  be  congenital, 
but  is  usually  an  accompaniment  of  paralysis  of  the  facial  nerve.  Marked 
protrusion  of  the  eyeball,  mechanically  preventing  closure  of  the  lid,  is 
seen  in  orbital  tumors,  exophthalmic  goitre,  and  in  corneal  staphyloma. 

Blepharospasm,  or  an  involuntary  contraction  of  the  eyelids,  may 
vary  in  degree  from  a  slight  twitching  of  a  few  of  the  fibres  of  the  orbicu- 
laris to  a  tonic  spasm.  In  its  simplest  form  it  is  due  to  uncorrected  refrac- 
tive errors,  inflammation  of  the  lid  borders,  and  corneal  and  conjunctival 
irritation.  Obstinate  cases  of  cramp  of  the  orbicularis  arise  from  reflex 
irritation  of  the  fifth  nerve,  through  some  remote  cause  that  it  is  often 
difficult  to  determine.     It  is  occasionally  a  hysterical  manifestation. 

Conjunctiva  and  Sclera. 

The  white  of  the  conjunctiva  changes  to  a  dull  yellow  in  so-called  bilious- 
ness, and  to  a  pronounced  brownish-yellow  color  in  icterus.  In  amemia, 
tuberculosis,  and  nephritis  the  conjunctiva  may  become  pearly  white. 

Inflammation. — The  normal  conjunctiva  is  coursed  by  a  few  small 
blood-vessels  which  arise  from  the  deep  furrow  where  the  membrane  is 
reflected  to  the  under  surface  of  the  lids.  Redness  is  the  result' of  a  marked 
increase  in  the  number  of  blood-vessels  from  inflammation  of  the  conjunc- 
tiva, or,  as  this  membrane  covering  the  eyeball  is  transparent,  to  congestion 
of  the  deep  sclera  beneath. 

Hyperemia  of  the  conjunctiva  is  seen  in  measles,  scarlet  fever,  hay 
fever,  influenza,  nasal  catarrh,  the  strain  of  uncorrected  refractive  errors 
and  from  exposure  to  wind,  dust,  and  bright  light  and  heat.  The  con- 
junctiva is  often  inflamed  in  facial  paralysis,  owing  to  the  inability  of  the 
lids  to  protect  the  globe  from  external  irritants.  The  presence  of  a  foreign 
body  on  the  conjunctiva  or  cornea  causes  many  of  the  characteristic  symp- 
toms of  an  acute  catarrhal  conjunctivitis. 

The  ordinary  conjunctival  inflammations  are  unattended  with  severe 
pain,  but  are  accompanied  with  a  mucous  or  mucopurulent  discharge.  In 
inflammation  of  the  sclera,  the  affected  area  is  seen  to  be  beneath  the  loose 
conjunctiva,  while  in  disease  of  the  iris,  ciliary  body  or  cornea,  a  ring  of 
fine  straight  vessels  surrounds  the  corneal  border.  In  these  latter  affections, 
pain  is  often  quite  severe.  Since  the  conjunctiva  may  be  also  inflamed  in 
disiase  of  these  deeper  structures,  a  diagnosis  cannot  be  made  by  the 
appearance  of  congestion  only. 

A  type  of  contagious  conjunctivitis  (acute  contagious  conjunctivitis) 
is  due  to  the  Koch- Weeks  bacillus  or  to  the  pneumococcus.  A  subacute 
form  of  conjunctival  inflammation,  which  may  occur  in  epidemie  form,  is 


372  MEDICAL  DIAGNOSIS. 

caused  by  the  diplobacillus  of  Morax  and  Axenfeld.  Severe  inflammation, 
with  swelling  of  lids,  infiltration  of  the  conjunctiva,  and  a  purulent  dis- 
charge, occurs  from  the  entrance  of  infection,  usually  the  gonococci,  into 
the  eyes  of  the  child  from  the  birth  canal  (ophthalmia  neonatorum).  A 
similar  form  of  inflammation  follows  the  entrance  of  gonorrhceal  pus  into 
the  conjunctival  sac  of  the  adult  (gonorrhceal  conjunctivitis).  A  purulent 
conjunctivitis  may  occur  in  young  girls  under  10  years  of  age  who  have  a 
vaginal  discharge.  Usually  this  discharge  contains  a  few  gonococci.  In 
institutions  the  disease  frequently  becomes  epidemic.  A  vaginal  discharge 
in  children,  which  does  not  contain  gonococci,  may  cause  a  mild  conjunctivitis. 

Diphtheria  of  the  conjunctiva  is  rare.  A  membrane  forms  on  the 
surface  of  the  conjunctiva,  presenting  the  same  characteristics  as  that  found 
in  the  throat.  A  pseudomembranous  conjunctivitis  may  be  due  to  the 
pneumocoecus  or  to  streptococcus  infection,  and  to  some  of  the  other  micro- 
organisms found  in  the  ordinary  types  of  inflammation. 

Roughness  or  elevation  of  the  conjunctiva  of  the  lids  may  indicate 
trachoma  or  vernal  catarrh.  Distended  and  tortuous  vessels  in  the  con- 
junctiva may  be  due  to  constipation,  auto-intoxication,  chronic  alcoholism 
or  lithasmia. 

Single  or  multiple  blebs  appear  on  the  conjunctiva  in  badly  nourished 
children,  often  after  measles.  Eczema  of  the  nares  and  disease  of  the 
nasopharynx  are  usually  coexistent. 

Hemorrhage  beneath  the  conjunctiva  appears  in  injuries  of  the  head, 
and  also  in  severe  compression  of  the  abdomen  or  thorax.  It  is  not  uncommon 
in  whooping-cough,  after  severe  vomiting,  and  in  obstinate  constipation,  the 
straining  causing  a  rupture  of  one  of  the  conjunctival  vessels.  Spontaneous 
hemorrhage  in  the  aged,  especially  if  recurrent,  should  direct  attention  to 
the  possibility  of  disease  of  the  blood-vessels  and  to  nephritis. 

Uric  acid  deposits  are  frequently  found  in  the  conjunctiva  of  the 
lids  of  gouty  individuals. 

Tumors  and  cysts  of  various  kinds  may  appear  in  the  conjunctiva  of 
the  eyeball.  Small,  yellowish  elevations  are  found  near  the  cornea,  usually 
at  the  inner  portion,  but  are  of  little  significance.  A  fleshy  fan-shaped 
growth  is  often  seen  in  persons  past  40  years  whose  eyes  have  been  sub- 
jected to  long  exposure  to  wind,  dust  or  sand.  The  usual  situation  is  over 
the  internal  rectus  muscle,  the  apex  often  extending  upon  the  cornea.  Most 
of  the  malignant  growths  appear  at  the  junction  of  the  sclera  and  cornea. 

Inflammation  of  the  sclera  is  found  in  association  with  the  rheumatic 
and  gouty  diathesis,  tuberculous,  intestinal  disorders  and  in  syphilis.  Tu- 
berculous scleritis  is  secondary  to  disease  of  the  anterior  uveal  tract,  and  is 
associated  with  corneal  inflammation.  In  the  superficial  form  of  inflamma- 
tion (episcleritis)  there  is  usually  a  circumscribed  area  of  purplish  discolora- 
tion beneath  the  conjunctiva,  most  frequently  in  the  region  of  the  external 
rectus  muscle,  and  slightly  raised  above  the  healthy  sclera.  In  disease  of 
the  true  sclera  (scleritis)  the  inflammation  may  affect  the  entire  anterior 
portion,  and  extend  to  the  cornea,  iris,  and  ciliary  body.  Affections  of 
sclera  are  distinguished  from  conjunctivitis  by  the  engorgement  of  the 
deeper  vessels,  the  purplish  color,  the  severe  pain,  the  absence  of  discharge, 
and  the  frequent  relapses. 


EXAMINATION  OF  THE  EYE.  373 

Cornea. 

Keratitis. —  The  cornea  is  subject  to  both  ulcerative  and  non-ulcerative 
affections. 

Ulcerative  Keratitis. — Loss  of  sensibility  of  the  cornea,  with  subse- 
quent ulceration  and  destruction,  is  found  in  affections  of  the  trunk  of  the 
fifth  nerve  or  of  its  ganglion,  or  after  removal  of  the  latter  for  trifacial 
neuralgia.  The  corneal  affection  is  due  to  a  trophic  change  in  the  membrane 
and  to  the  irritation  of  foreign  substances,  which  are  not  recognized  by 
the  insensitive  cornea. 

A  severe  type  of  corneal  ulceration,  which  may  progress  to  perforation, 
is  found  in  association  with  herpes  of  the  region  about  the  eyes,  particularly 
of  the  lachrymal  branch  of  the  trifacial.  The  disease  is  preceded  by  severe 
burning  and  neuralgic  pain,  in  isolated  spots,  upon  which  are  developed 
the  characteristic  vesicles. 

Phlyctenular  Keratitis. — Small  blebs,  later  forming  ulcers,  occur 
on  the  cornea  or  at  the  scleral  junction  in  strumous  children,  and  are  asso- 
ciated with  inflammatory  diseases  of  the  nasal  passages,  often  following 
the  exanthematous  fevers.  Eczema  about  the  nares  is  usually  coexistent 
Abscess  and  ulceration  may  occur  in  measles,  smallpox,  scarlet  fever  and 
other  infections.  Exophthalmic  goitre  may  give  rise  to  extensive  ulceration 
owing  to  constant  exposure  of  the  cornea.  Severe  ulceration  of  the  centre 
of  the  cornea  may  follow  the  exhaustion  of  a  prolonged  diarrhoea,  dysentery, 
or  other  debilitating  illness  in  the  aged. 

Interstitial  Keratitis. — Inflammation  of  the  deeper  layers  of  the 
cornea,  without  ulceration,  is  frequently  seen  in  children,  between  5  and 
15  years  of  age,  who  have  inherited  syphilis,  and  also  in  tubercular,  scrofu- 
lous, and  other  poorly  nourished  individuals.  In  its  earliest  stage  the  con- 
gestion surrounding  the  cornea  is  of  the  deep  vessels,  there  is  dread  of 
light,  and  close  examination  shows  a  fine  dot-like  infiltration  of  the  inter- 
stitial layers  of  the  cornea,  which  later  coalesce  into  the  typical  bluish 
white  haziness.  The  affection  is  bilateral,  although  months  may  elapse 
before  the  second  eye  is  affected. 

Arcus  Senilis. — An  arc  of  fatty  degeneration  within  the  cornea,  but  with 
a  clear,  narrow  band  of  corneal  tissue  separating  it  from  the  sclera,  is  present 
in  the  eyes  of  persons  of  advanced  years,  although  it  is  sometimes  seen 
before  middle  life.  It  possesses  no  significance.  A  senile  atrophy  of  the 
margin  of  the  cornea  has  been  described  in  association  with  arcus  senilis. 

Partial  insensibility  of  the  cornea  is  Been  in  exophthalmic  goitre,  and 
its  presence  probably  explains  a  number  of  the  other  eye  symptoms. 

The  Iris  and  Pupil. 

Pigmentation. —  Slight  variation  in  the  pigmentation  of  the  irides  is  not 
uncommon  in  health,  but  difference  in  color  is  rate,  except  in  disease.  A 
yellow  green  color  of  one  iris,  while  the  other  is  blue  or  brown,  is  an  early 
evidence  of  inflammation  of  the  iris  and  ciliary  body.  It  also  occurs  as  a 
congenital  condition,  and  the  eye  with  the  lighter  colored  iris  often  Later 
develops  cataract.  Retained  metallic  foreign  bodies  often  cause  tin1  iris  to 
assume  the  brownish  hue  to  which  the  term  siderosis  is  given.     Inflammation 


374  MEDICAL  DIAGNOSIS. 

of  the  iris  occurs  in  syphilis,  rheumatism,  gout,  tuberculosis,  diabetes,  and 
from  injuries,  primarily  in  one  eye,  or  in  the  fellow  eye  from  sympathy. 
It  is  accompanied  by  irregularity  and  contraction  of  the  pupil,  injection 
of  the  pericorneal  vessels,  and  frontal  pains,  usually  worse  at  night.  Swelling 
in  the  stroma  of  the  iris  is  a  sign  of  tertiary  syphilis.  Sarcoma,  as  a  primary 
disease,  is  rare. 

The  Pupil. — Variations  in  the  size  of  the  pupil  occur  under  the  influ- 
ence of  light,  and  in  convergence  and  accommodation.  The  average  size 
of  the  pupils,  in  diffuse  daylight,  with  the  eyes  fixed  on  a  distant  point, 
is  4  mm.  Careful  tests  of  changes  in  the  pupils  are  of  importance  in  the 
diagnosis  of  general  affections,  particularly  of  the  nervous  system. 

The  normal  reactions  are  as  follows : 

1.  Direct  Eeaction. — If  one  eye  is  excluded,  and  the  patient  directed 
to  fix  a  distant  object,  the  pupil  of  the  exposed  eye,  when  covered  by  the 
hand  or  card,  will  dilate.  Upon  removal  of  the  cover  it  will  contract  to 
its  previous  size. 

2.  Indirect  Reaction  (Consensual  Reflex). — If  one  eye  is  shaded, 
the  other  pupil  will  dilate  equally  with  the  shaded  pupil,  to  again  contract 
when  the  shade  is  removed.  Normally  the  two  pupils  should  be  of  equal 
size,  whether  one  or  both  is  covered  or  uncovered. 

3.  Associated  Reaction  (Reflex  to  Accommodation  and  Conver- 
gence) . — The  patient  is  directed  to  look  into  the  distance  and  then  converge 
the  eyes  on  a  point,  such  as  a  pencil,  held  about  5  inches  from  the  eye.  The 
pupils  contract  under  the  influence  of  the  convergence  and  accommodation. 

4.  Sensory  Reaction  (Skin  Reflex). — Stimulation  of  the  sensory 
nerves  of  the  skin,  by  pinching  the  skin  of  the  neck,  or  by  the  passage  of 
a  faradic  brush  along  the  spine,  causes  slight  dilatation  of  the  pupils. 

5.  Orbicularis  Pupillary  Reaction  (Lid-closure  Reflex). — Con- 
traction of  the  pupils  occurs  upon  forcible  efforts  to  close  the  lids. 

6.  Drug  Reaction. — Dilatation  of  the  pupil  (mydriasis)  follows  the 
instillation  of  mydriatic  drugs,  and  contraction  of  the  pupil  (myosis)  the 
instillation  of  myotics. 

7.  Cerebral  Cortex  Pupillary  Reflex. — If  a  patient  seated  in  a  dark 
room,  with  the  eyes  fixe'd  at  the  black  wall,  and  a  light  placed  to  shine 
laterally  into  the  eyes,  is  requested  to  direct  his  attention  to  the  light,  without 
changing  the  position  of  the  eyes,  the  pupils  will  contract.  Since  the  accom- 
modation remains  suspended,,  and  the  light  entering  the  eye  is  unchanged, 
the  contraction  of  the  pupil  is  in  some  manner  connected  with  the  power 
of  attention ;  the  test  should  therefore  be  made  in  cases  of  nervous  disorder. 

Myotic  Pupillary  Tract. — Stimulation  of  the  centre  for  the  third 
nerve,  by  the  action  of  light  passing  along  the  optic  nerve  and  optic  tracts, 
causes  an  impulse  to  pass  to  the  lenticular  ganglion,  and  thence  by  the 
short  ciliary  nerves  to  the  sphincter  of  the  pupil,  which  contracts,  lessening 
the  size  of  the  pupil. 

Mydriatic  Pupillary  Tract. —  The  dilator  muscle  of  the  iris  is  inner- 
vated by  the  sympathetic.  The  impulse  passes  from  the  medulla  into 
the  cord,  thence  through  the  first  three  dorsal  nerves  to  the  superior  cervical 
ganglion,  to  the  plexus  around  the  internal  carotid,  and  through  the  long 


EXAMINATION  OF  THE  EYE.  375 

ciliary  nerves  to  the  ciliary  muscle  and  iris.     Stimulation  of  the  centres 
of  this  tract  causes  dilatation  of  the  pupil. 

Abnormal  Pupillary  Reactions. — Failure  of  the  pupil  to  react,  either 
wholly  or  in  part,  is  due  to  a  lesion  in  the  iris,  in  some  part  of  the  third 
nerve,  in  the  centres  of  the  brain,  or  in  the  light-conducting  paths.  Lesions 
in  the  iris  may  be  swelling  or  atrophy,  or  old  or  recent  attachments 
from  inflammation.  Immobility  to  light  stimulus,  with  preservation  of 
the  reflex  to  accommodation,  is  one  of  the  important  abnormal  pupillary 
changes. 

Reflex  Immobile  Pupil  (Argyll-Robertson  Pupil). — Loss  of  reac- 
tion of  the  pupil  to  direct  light,  with  preservation  of  the  contraction  of  the 
iris  in  accommodation  and  convergence,  comprises  the  well-known  Argyll- 
Robertson  pupil,  and  is  an  early  symptom  of  tabes.  Although  of  great 
diagnostic  value  when  present, — and  in  the  majority  of  cases  it  exists  in 
the  incipient  stages  of  the  disease, — there  are  rare  instances  in  which  it 
has  not  been  found,  even  when  all  other  symptoms  of  the  disease  have  existed 
for  years.  Associated  with  lost  light  reflex  is  frequently  noticed  alteration 
in  the  shape  of  the  pupil.  The  pupil  may  be  of  normal  size,  but  more  often 
myosis  is  found,  from  implication  of  the  cervical  portions  of  the  cord 
controlling  the  dilating  centres.  The  Argyll-Robertson  pupillary  phe- 
nomenon is  also  seen  in  paretic  dementia.  The  loss  of  the  light  retiex  in 
aortic  disease  is  due  to  the  general  sj'philitic  infection. 

Dilatation  of  the  Pupil. — The  pupil  is  dilated  in  glaucoma,  in  optic 
atrophy,  in  diseases  of  the  orbit,  in  irritation  of  the  cervical  sympathetic, 
in  acute  mania,  in  cerebral  softening,  in  extensive  disease  or  injury  of  the 
cerebral  centres,  in  complete  paralysis  of  the  third  nerve,  in  paralysis  of 
the  sphincter  of  the  iris  by  a  blow  upon  the  eyeball,  in  strong  emotion, 
and  when  mydriatics  have  been  used.  In  neurasthenia  and  hysteria,  my- 
driasis is  often  present. 

Dilatation  of  the  pupil  may  be  caused  by  an  irritation  of  the  dilator 
pupillary  centre  or  tract  (irritative mydriasis),  or  by  a  paralysis  of  the 
pupil-contracting  centre  or  fibres  (paralytic  mydriasis). 

Unilateral  mydriasis,  in  which  the  pupil  fails  to  react  to  direct  light 
but  contracts  consensually  with  its  fellow,  is  seen  in  complete  optic  atrophy, 
in  which  the  conductivity  of  the  one  optic  nerve  is  lost.  The  failure  of  one 
pupil  to  retract  to  separate  stimulation  of  either  eye,  but  contracting  upon 
convergence,  while  the  other  pupil  reacts  to  light  stimulus  of  either  eye, 
is  seen  in  tabes  and  in  syphilis.  Sudden  unilateral  mydriasis  in  which  the 
instillation  of  a  drug  can  be  excluded  is  a  possible  early  symptom  of  latent 
sclerosis  of  the  cord. 

Corte  claims  that  in  any  serious  diphtheritic  attack  failure  of  the 
pupils  to  read  to  light  indicates  a.  fatal  termination. 

Complete  blindness  will  cause  bilateral  mydriasis  with  failure  of  the 
pupils  to  react  to  light  stimulus.  A  slight  contraction  of  the  pupils  has 
hem  observed  in  the  blind,  who  are  entirely  devoid  of  light  perception, 
after  the  eyes  have  heen  exposed  to  bright  daylight  for  several   minutes. 

In  mydriasis  from  drugs,  the  accommodation  is  temporarily  suspended. 

Contraction  of  the  Pupil. — Abnormal  contraction  of  the  pupils  is 
due  either  to  irritation  of  the  pupil-contracting  centre  or  fibres,  or  to  paralysis 


376  MEDICAL  DIAGNOSIS. 

of  the  sympathetic.  In  disease  of  the  central  nervous  system,  the  myosis  may 
be  due  to  irritation  of  the  sphincter  nucleus;  but  should  mydriasis  follow 
the  myosis,  it  is  an  indication  of  the  spread  of  the  affection  and  destruction 
of  the  sphincter  centre.  In  irritative  myosis  the  pupil  rarely  dilates  under 
cover  or  in  a  bright  light,  but  acts  normally  when  a  mydriatic  or  myotic 
drug  is  instilled.  In  the  paralytic  myosis  the  reaction  to  light  and  in  con- 
vergence is  preserved,  but  the  pupils  dilate  imperfectly  when  shaded.  My- 
driatics act  imperfectly,  but  the  pupils  contract  further  to  myotics.  In 
old  age  the  pupils  are  usually  smaller  than  in  middle  life,  although  perfectly 
normal  in  reaction.  Inflammations  of  the  iris  are  always  associated  with 
small  pupils,  and  the  iris  is  likely  to  become  attached  to  the  lens  capsule. 
Myosis  is  seen  in  the  early  stages  of  inflammation  of  the  brain  and  meninges, 
apoplexy,  abscess,  and  in  other  affections  which  indicate  irritation  of  the 
part;  also  in  hysteria,  toxaemia,  and  in  epilepsy.  Paralytic  myosis  occurs 
in  tabes,  general  paralysis,  spinal  meningitis,  and  destructive  lesions  of 
the  cord. 

Unequal  pupils  (anisocoria)  may  point  to  purely  functional  affec- 
tions, such  as  hysteria  and  the  psychoses,  or  to  grave  organic  disease,  as 
paresis,  tabes,  etc.  The  pupillary  phenomena  must  be  studied  in  connec- 
tion with  other  symptoms  to  arrive  at  a  correct  diagnosis.  Inequality  of 
the  pupils,  although  the  reaction  to  light  remains,  is  present  in  many  cases 
of  exophthalmic  goitre.  Bichelonne  believes  that  unilateral  mydriasis  is  an 
important  sign  in  the  early  diagnosis  of  pulmonary  tuberculosis. 

Alternating  mydriasis,  in  which  the  dilatation  changes  from  one  eye 
to  the  other,  is  occasionally  present  in  general  paralysis  and  in  tabes,  and 
has  been  described  as  a  premonitory  symptom  of  insanity. 

Hippus. — An  alternate  contraction  and  dilatation  of  the  pupil,  occur- 
ring under  a  uniform  stimulus  of  light,  is  a  normal  phenomenon,  but  may 
be  excessive  in  hysteria,  epilepsy,  advanced  paralysis,  early  stages  of 
meningitis  and  mania,  and  in  phthisis. 

Hemiopic  Pupillary  Inaction. — The  Wernicke  pupil  is  described 
under  hemianopsia. 

Iritis. — Inflammation  of  the  iris  may  accompany  disease  of  or  trauma- 
tism to  other  ocular  structures,  or  be  due  to  constitutional  disorders.  The 
principal  signs  are  changes  in  the  color  of  the  iris,  injection  of  the  peri- 
corneal vessels,  myosis,  deposits  on  the  posterior  surface  of  the  cornea,  and 
attachments  of  the  iris  to  the  lens  capsule.  The  symptoms  are  severe  brow 
pain,  worse  at  night,  and  slowly  failing  vision. 

Syphilis  is  the  most  common  cause  of  iritis.  The  inflammation  affects 
both  eyes,  one  later  than  the  other,  usually  appears  from  the  second  to  the 
eighth  month  following  the  initial  infection,  and  is  plastic  in  character.  In 
some  instances  one  or  more  yellowish  brown  nodules  may  appear  at  or  near 
the  pupillary  border,  resembling  the  solitary  gumma  of  the  tertiary  period 
of  syphilis. 

It  is  probable  that  the  iritis,  so  long  considered  as  due  to  rheumatism, 
is  septic  or  toxic  in  origin,  often  from  the  gastro-intestinal  tract.  The  in- 
flammation is  usually  unilateral,  although  the  second  eye  may  later  become 
affected.  In  chronic  rheumatic  subjects  the  iritis  is  of  a  severe  and  de- 
structive type.     The  attacks  usually  recur  during  a  relapse  of  the  rheuma- 


EXAMINATION  OF  THE  EYE.  377 

tism,  or  they  may  be  the  only  evidence  of  the  toxaemia.  The  so-called  idio- 
pathic iritis,  in  which  syphilis,  gonorrhoea,  and  traumatism  can  be  positively 
excluded,  is  often  secondary  to  disorders  of  nutrition  or  constitutional  affec- 
tions. In  these  cases  the  pain  is  usually  of  greater  severity,  the  disease  more 
slowly  amenable  to  treatment,  and  the  relapses  frequent. 

In  severe  inflammations  of  the  iris,  the  ciliary  body  is  involved,  and 
the  disease  is  referred  to  as  irido-cyclitis.  Uveitis,  or  inflammation  of  the 
iris,  ciliary  body,  and  choroid,  occurs  in  rheumatism  and  gout,  diabetes, 
influenza,  anaemia,  syphilis,  tuberculosis  and  the  specific  fevers;  also  in 
affections  of  the  teeth,  tonsils,  accessory  sinuses,  the  prostate  and  the  skin. 
The  disease,  which  is  probably  the  manifestation  of  some  toxic  process,  is 
characterized  by  moderately  deep  anterior  chamber,  hazy  cornea  and  aque- 
ous, pupil  not  contracted,  occasionally  a  slight  increase  in  the  tension  of 
the  eyeball,  and  the  deposit  in  triangular  form  of  small  dots  on  the  posterior 
surface  of  the  cornea. 

Irido-cyclitis  is  often  seen  during  the  late  stages  of  gonorrhoea,  and 
recurs  with  relapses  of  the  disease.  The  iritis  may  occur  a  considerable 
time  after  the  acute  attack,  sometimes  preceding  or  following  an  affection  of 
the  joints. 

Tubercle  of  the  iris  is  seen  as  two  or  more  reddish  nodules  in  the 
anterior  surface  or  deep  in  the  iris  tissue,  occasionally  in  confluent  form, 
in  young  persons,  usually  between  the  tenth  and  twentieth  year.  The 
patients  may  not  present  other  active  manifestations  of  the  tuberculous- 
process.    Koch's  old  tuberculin  may  be  employed  for  diagnostic  purposes. 

Ocular  Muscles. 

Mobility  of  the  Eyes. — Under  normal  conditions,  the  eyeballs  move 
in  perfect  accord  in  all  directions,  with  no  manifest  lagging  movement  in 
either  eye  in  any  of  the  several  rotations.  In  equilibrium  of  the  ocular 
muscles,  every  movement  of  one  eye  is  accompanied  by  simultaneous  and 
equal  movement  of  the  other,  the  image  of  the  object  upon  which  the  eyes 
are  fixed  is  formed  on  the  fovea  of  each  eye,  and  the  effort  required  on 
the  part  of  any  one  muscle  or  group  of  muscles  in  sustaining  binocular  single 
vision  is  equal  in  the  two  eyes. 

Disturbance  of  equilibrium  may  be  arranged  in  two  groups: 

1.  Organic  anomalies,  in  which  there  is  double  vision  in  attempts  to 
rotate  the  eyes  in  the  direction  of  the  affected  or  paralyzed  muscle  or 
group  of  muscles. 

2.  Functional  anomalies,  in  which  there  are: 

(a)  An  actual  deviation  of  the  visual  line  of  one  eye  from  that  of  the 
other,  persisting  in  all  movements  of  the  two  eyes. 

(b)  A  tendency  to  deviation,  which  is  overcome  by  increased  or  de- 
creased innervation  to  the  muscle  or  group  of  muscles  affected. 

Organic  Anomalies  (Ocular  Palsies). —  Since  binocular  single  vision 
can  only  be  maintained  if  the  image  of  the  object  falls  upon  the  macula 
of  each  eye  or  Upon  corresponding  points  of  each  retina,  any  disturbance 
of  the  motor  apparatus  by  palsy  of  one  or  more  of  the  ocular  muscles  results 
in  an  impression  of  the  object  upon  non-corresponding  points  of  each  retina. 


378  MEDICAL  DIAGNOSIS. 

Two  images  are,  therefore,  transmitted  to  the  brain,  and  double  vision,  or 
diplopia,  results.  The  symptoms  of  ocular  palsies  are:  (1)  diplopia;  (2) 
limitation  of  movement  of  one  or  both  eyes  in  the  direction  of  the  paralyzed 
muscle;  (3)  actual  deviation;  (4)  false  protection;  (5)  vertigo;  and  (6) 
abnormal  position  of  the  head. 

Diagnosis  of  Ocular  Palsies. — Paralysis  of  an  ocular  muscle  is 
to  be  suspected  if  the  patient  complains  of  seeing  double  or  tilts  the  head 
to  prevent  diplopia,  and  complains  of  vertigo  in  attempts  to  fix  an  object 
in  that  portion  of  the  field  in  which  double  vision  exists.  If  the  paralysis 
is  complete,  the  eye  with  the  affected  muscle  fails  to  rotate  past  the  median 
line  when  the  object  fixed  passes  to  the  side  to  which  the  affected  muscle 
ordinarily  rotates  the  eye,  and  in  fixation  with  the  affected  eye,  the  devia- 
tion of  the  sound  eye  (secondary  deviation)  is  greater  than  is  the  deviation 
of  the  squinting  eye  when  the  sound  eye- fixes  (primary  deviation). 

Diplopia. — In  partial  paralysis  the  limitation  of  rotation  may  be  so 
slight  as  to  escape  observation.  It  becomes  manifest,  however,  even  in  slight 
degrees,  upon  the  tests  for  diplopia.  The  patient,  seated  in  a  darkened 
room,  with  the  head  fixed  in  one  position,  is  directed  to  follow'  with  the  eyes 
a  lighted  candle  held  at  a  distance  of  about  10  feet,  and  moved  in  all  portions 
within  the  field  of  vision.  If  a  piece  of  colored  glass  is  held  before  one  eye, 
the  images  of  the  two  eyes  are  in  this  way  differentiated.  By  this  test  the 
behavior  of  the  two  images  in  their  relative  height  and  distance  from  each 
other,  and  their  separation  and  approximation,  as  the  light  is  carried  up  and 
down,  to  the  right  and  to  the  left  of  the  patient,  determines  which  of  the 
muscles  is  palsied.  Special  skill  and  training  are  essential  in  the  diagnosis 
of  the  more  complex  forms  of  palsies,  and  it  is  unnecessary  in  this  connection 
to  enter  fully  into  details,  but  the  following  points  will  serve  to  indicate 
roughly  the  character  of  the  affection: 

1.  Double  images  are  seen  only  when  the  eyes  are  turned  in  the  direc- 
tion in  which  the  paralyzed  muscle  or  muscles  normally  rotate  the  eye ;  in 
all  other  directions  there  is  single  vision. 

2.  The  image  of  the  eye  with  the  paralyzed  muscle  (false  image) 
separates  from  the  image  of  the  sound  eye  (true  image)  as  the  object  is 
carried  into  the  field  governed  by  the  muscle  affected ;  that  is,  the  distance 
between  the  double  images  increases  as  the  object  fixed  upon  is  moved  in 
the  direction  toward  which  the  paralyzed  muscle  should  rotate  the  eye. 

If  the  false  image  is  on  the  same  side  as  the  affected  eye  the  diplopia 
is  homonymous;  if  the  false  image  is  projected  to  the  side  of  the  sound 
eye  the  diplopia  is  crossed,  or  heteronymous. 

Homonymous  diplopia,  with  images  in  the  same  horizontal  plane,  indi- 
cates paralysis  of  an  external  rectus,  right  externus  if  the  images  separate 
as  the  object  fixed  is  carried  to  the  right,  and  left  externus  if  they  separate 
as  the  object  fixed  is  carried  to  the  left. 

Crossed  diplopia  in  the  horizontal  plane  indicates  paralysis  of  an 
interims,  right  interims  if  the  double  images  separate  in  looking  to  the  left, 
and  the  left  interims  if  they  separate  in  looking  to  the  right. 

Vertical  diplopia  in  upper  field  (that  is,  one  image  higher  than  the 
other)  indicates  a  paralysis  of  the  superior  rectus  or  inferior  oblique:  if 
diplopia  increases  in  looking  up  and  to  the  right,  and  image  of  right  eye  is 


EXAMINATION  OF  THE  EYE.  379 

higher,  paralysis  of  right  superior  rectus;  if  lower,  left  inferior  oblique. 
Increase  in  diplopia  in  looking  up  and  to  the  left,  with  image  of  right  eye 
higher,  paralysis  of  right  inferior  oblique ;  if  lower,  left  superior  rectus. 

Vertical  diplopia  in  lower  field  shows  a  paralysis  of  the  inferior  rectus 
or  superior  oblique.  Increase  in  the  diplopia  in  looking  down  and  to  the 
right,  with  image  of  right  eye  lower,  indicates  paralysis  of  right  inferior 
rectus;  if  higher,  left  superior  oblique.  Diplopia  increasing  down  and  to 
the  left,  with  image  of  right  eye  higher,  shows  paralysis  of  right  superior 
oblique,  if  lower,  left  inferior  rectus. 

Special  Palsies.  —  Paralysis  of  the  Sixth  Nerve. — The  long  course 
of  the  sixth  nerve  at  the  base  of  the  brain  renders  it  particularly  liable 
to  pressure  from  inflammatory  exudation,  hemorrhage,  and  fracture.  It 
is  the  most  frequent  of  the  ocular  palsies,  and  it  is  indicated  by  conver- 
gence of  the  affected  eye.  homonymous  diplopia,  and  inability  of  the  eye  to 
rotate  outwards  past  the  median  line. 

Paralysis  of  :the  third  nerve  is  shown  by  ptosis,  the  pupil  moder- 
ately dilated  and  anresponsive,  the  power  of  accommodation  abolished,  and 
crossed  diplopia,  with  the  eyeball  turned  outward  and  slightly  downward 
from  the  action  of  the  external  rectus  and  superior  oblique.  In  cycloplegia 
only  that  portion  of  the  nerve  controlling  the  ciliary  muscle  is  affected. 
There  may  or  may  not  be  associated  paralysis  of  the  sphincter  of  the 
pupil  (iridoplegia). 

Paralysis  of  the  fourtf  nerve,  which  controls  the  superior  oblique, 
is  less  frequent.  There  is  vertical  diplopia  in  the  lower  field,  the  image 
of  the  affected  eye  is  the  lower,  and  the  distance  between  the  images  increases 
as  the  eye  is  rotated  downwards  and  inwards. 

Ophthalmoplegia  externa  is  the  term  employed  to  designate  paralysis 
of  all  the  external  ocular  muscles.  The  affected  eye  is  incapable  of  movement, 
and  the  lid  droops  and  cannot  be  voluntarily  raised.  Paralysis  of  the  iris 
and  ciliary  muscle  is  known  as  ophthalmoplegia  interna. 

Conjugate  Palsy. — In  this  rare  affection  the  individual  muscles  of 
each  eye  possess  their  normal  power  to  turn  the  globe  in  any  desired  posi- 
tion, but  there  is  inability  to  rotate  the  two  eyes  in  associated  action.  It 
may  affect  convergence,  so  that  the  eyeballs  cannot  be  converged,  although 
individually  capable  of  internal  rotation:  or  it  is  shown  in  loss  of  associated 
lateral  or  vertical  movements.  In  all  cases  the  lesion  is  central,  and  involves 
the  centres  for  conjugate  movement,  although  spasmodic  conjugate  deviation 
is  seen  in  hysteria. 

Causes  of  Ocular  Palsies.  —  Paralysis  of  the  ocular  muscles  may  be  due 
to  an  intracranial  or  an  orbital  lesion  or  to  peripheral  causes;  it  may  follow 
meningitis,  tumors,  hemorrhage,  gumma,  or  vascular  changes  in  the  brain; 
orbital  cellulitis,  traumatism,  and  inflammation  of  the  nerve  in  the  muscle. 
The  constitutional  causes  are  syphilis,  tuberculosis,  diabetes,  nephritis,  in- 
fluenza, tabes,  rheumatism,  diphtheria,  and  general  paresis. 

At  least  one-half  of  the  ocular  palsies  are  considered  to  be  due  directly 
to  syphilitic  gummatous  deposits,  syphilitic  periostitis  in  the  orbit  or  along 
the  base,  of  to  degeneration  in  or  close  to  the  nuclei  of  the  nerves.  These 
are  exclusive  of  the  indirect  syphilitic  affections,  as  manifested  in  tabes. 
general  paresU,  and  diseases  of  the  blood-vessels.     Nuclear  and  peripheral 


380  MEDICAL  DIAGNOSIS. 

palsies  may  be  caused  by  rheumatism,  diabetes,  tonsillitis,  influenza,  ptomaine 
poisoning,  and  by  lead,  alcohol,  tobacco,  and  other  toxic  agents.  In  that 
variety  of  ptomaine  poisoning  known  as  botulismus,  nuclear  palsies  are  fre- 
quent. Basal  palsies  are  seen  in  hemorrhage,  meningitis,  especially  tuber- 
cular, abscess,  and  cavernous  sinus,  disease.  The  paralyses  associated  with 
diabetes  mellitus  develop  suddenly,  but  usually  are  of  short  duration  and 
mostly  affect  the  sixth  nerve.  Neuralgia  of  the  region  about  the  eye  is  often 
associated  with  the  paralysis,  and  pain  in  this  situation  should  direct  atten- 
tion to  a  possible  disturbance  of  the  motor  apparatus  on  the  same  side. 

Ophthalmoplegia  interna,  or  paralysis  of  the  ciliary  muscle  and  the 
sphincter  of  the  pupil,  is  more  frequently  unilateral  than  bilateral,  and  is 
seen  in  syphilis,  tabes,  and  intracranial  disease.  Either  the  sphincter  or 
the  ciliary  muscle  may  be  first  affected,  and  later  the  external  ocular  muscles 
become  implicated.  It  is  also  found  after  diphtheria.  The  lesion  is  probably 
nuclear. 

Paralysis  of  the  accommodation,  destroying  the  power  of  reading, 
is  seen  in  about  5  per  cent,  of  cases  of  diphtheria,  usually  affects  both  eyes, 
and  only  rarely  isi  associated  with  palsy  of  the  iris.  Occasionally  paralysis 
of  the  external  rectus  is  associated  with  the  loss  of  accommodation.  Similar 
palsies  are  seen  in  severe  cases  of  influenza. 

Intermittent  palsy  of  one  or  more  muscles  is  an  early  symptom  of 
tabes.  One  eye  is  generally  affected,  and  the  paralysis  disappears  in  a  few 
weeks  to  again  recur.  The  external  rectus  is  probably  the  most  frequently 
involved,  and  next  the  muscles  supplied  by  the  third  nerve,  either  as  a  group 
or  individually,  while  the  parts  supplied  by  the  fourth  nerve  are  rarely 
affected. 

Palsies  of  some  of  the  ocular  muscles,  most  frequently  those  supplied 
by  the  third  nerve,  are  present  in  "ophthalmoplegic  migraine"  and  follow 
the  subsidence  of  pain.  The  attacks  are  usually  recurrent,  the  palsy  occur- 
ring on  the  same  side  as  the  pain.  The  disease  is  rare,  and  should  be  differen- 
tiated from  brain  tumor. 

Functional  Anomalies. — Both  of  the  functional  defects,  the  tendency  to 
deviation  (heterophoria)  and  the  actual  turning  of  one  visual  line  from  that 
of  its  fellow  (heterotopia,  or  functional  squint),  are  due  in  many  instances 
to  errors  of  refraction,  alid  to  disturbance  of  the  relation  between  conver- 
gence and  accommodation.    There  is  no  paralysis  and  no  double  vision. 

Latent  Deviations  (Heterophoria,  Insufficiency  of  the  Ocular 
Muscles). — If  there  is  a  lack  of  equilibrium  in  the  action  of  the  muscles  of 
the  two  eyes  in  binocular  vision,  so  that  fixation  of  the  eyes  is  only  main- 
tained through  an  excessive  amount  of  nerve  force  expended  in  helping 
the  weak  muscle  or  set  of  muscles,  there  follows  a  train  of  symptoms  which 
is  usually  included  under  the  term  muscular  asthenopia:  There  is  more 
or  less  constant  dull  headache,  which  may  be  general  or  localized  in  the 
frontal  or  occipital  region,  blurred  vision,  inability  to  use  the  eyes  at  near 
work,  and  photophobia.  Sometimes  there  may  be  vertigo  and  nausea,  con- 
fusion of  ideas,  insomnia,  and  a  feeling  of  physical  exhaustion  while  in  a 
moving  crowd,  in  attendance  at  the  theatre,  or  after  riding  in  the  cars. 
Heterophoria  is  a  most  active  causative  factor  in  many  of  the  reflex  nervous 
disorders.    Relief  in  many  oases  has  undoubtedly  followed  the  correction  of 


EXAMINATION  OF  THE  EYE.  381 

the  defects,  but  does  not  justify  the  extravagant  claims  made  that  epilepsy, 
chorea,  melancholia,  dyspepsia,  and  other  affections  are  not  only  primarily 
due  to  heterophoria,  but  are  cured  after  correction  of  the  muscle  anomaly. 

Forms  of  Deviation. — The  tendency  of  the  visual  lines  to  deviate  from 
the  normal  parallelism  is  divided  into  esophoria,  a  tendency  of  the  visual 
lines  to  turn  inward;  cxophoria,  a  tendency  of  the  visual  lines  to  turn 
outward;  and  hyperphoria,  a  tendency  of  one  visual  line  to  deviate  above 
that  of  its  fellow.  The  inward  tendency  of  the  visual  lines  is  of  relatively 
less  importance  as  a  cause  of  reflex  symptoms  than  is  hyperphoria  or 
exophoria. 

To  determine  the  existence  of  the  muscle  anomaly,  the  latent  defect 
is  made  manifest  by  means  of  a  prism  of  sufficient  strength  to  cause  diplopia, 
or  by  the  use  of  a  piece  of  cobalt  glass  or  a  rod  of  glass  held  before  the  eye. 
The  line  of  light  made  by  the  rod  is  so  dissimilar  from  the  image  of  the  other 
eye  that  the  fusion  impulse  is  abolished,  and  the  eyes  take  the  position  of 
greatest  rest.  The  prism  that  fuses  the  double  images  made  by  the  prism  or 
brings  the  line  of  light  into  the  flame  seen  by  the  other  eye  is  the  measure  of 
the  defect.    Correction  of  the  refraction  is  essential  to  a  cure. 

Manifest  Deviations  (Concomitant  Squint,  Heterotropia). — In  this 
affection  there  is  an  actual  deviation  of  one  visual  line  from  that  of  the  other, 
but  the  squinting  eye  is  able  to  follow  the  movements  of  the  fixing  eye  in 
all  directions ;  there  is  no  acknowledged  diplopia,  and  the  deviation  is  trans- 
ferred from  one  eye  to  the  other,  and  remains  of  the  same  degree  upon 
alternately  covering  one  eye  and  then  the  other.  The  absence  of  double 
vision,  and  the  fact  that  the  power  of  rotation  of  the  eye  is  not  limited,  serve 
to  distinguish  the  functional  from  the  paralytic  squint. 

Functional  squint  may  be  either  convergent,  divergent,  or  vertical. 
The  three  principal  causes  of  the  strabismus  are  a  disturbance  in  the  normal 
relation  between  convergence  and  accommodation,  brought  into  existence 
by  errors  of  refraction ;  a  weakness  of  opposing  muscles,  either  through 
structural  changes  or  disturbed  innervation ;  and  unequal  vision  of  the  two 
eyes,  so  that  the  normal  desire  for  fusion  is  abolished.  The  strabismus  may 
be  monolateral,  when  one  eye  always  fixes  and  the  other  always  squints ;  or 
alternating,  when  either  eye  may  be  used  for  fixation,  since  the  visual  acuity 
is  about  the  same  in  each.  Squint  is  an  affection  of  early  childhood,  often 
disappearing  if  proper  treatment  is  instituted  at  this  time. 

Vision. 

AFFECTIONS  OF  VISION. 

Imperfect  vision  is  due  to  errors  of  refraction  ;  to  opacities  of  the  cornea, 
crystalline  lens,  or  vitreous;  to  disease  of  the  retina,  choroid,  optic  nerve,  or 
central  nervous  system;  or  to  functional  neurosis. 

Central  vision  is  tested  by  means  of  letters  corresponding  in  size  to 
a  fixed  standard.  The  patient,  seated  20  feet  from  the  test  card,  and  one 
eye  covered,  is  asked  to  read  the  smallest  line  of  letters  1  hat  can  be  deciphered. 
If  the  vision  thus  estimated  does  not  conform  to  the  standard,  the  various 
errors  of  refraction  should  be  excluded  before  concluding  that  the  reduced 
vision  is  the  result  of  disease.     This  may  be  done  by  placing  before  the  eye 


382 


MEDICAL  DIAGNOSIS. 


an  opaque  disk  with  a  small  central  opening.  If  no  urganic*  disease  exists 
vision  will  conform  to  the  normal.  The  effect  of  faulty  vision  upon  the 
health  of  patients  is  oftentimes  overlooked.  In  a  person  given  to  any  manner 
of  indoor  vocation,  whose  nervous  system  is  at  all  delicately  balanced,  an 
uncorrected  eye-strain  may  give  rise  to  headache,  drowsiness,  transient  ver- 
tigo, and  sometimes  to  nausea,  irritability  of  temper,  and  insomnia.  These 
symptoms  are  probably  more  often  found  when  vision  is  in  excess  of  the 
normal  standard,  hence  the  state  of  the  refraction  must  be  learned  in  order 
to  determine  the  extent  to  which  the  accommodative  strain  is  responsible  for 
the  reflex  manifestation. 

Peripheral  Vision. — In  testing  the  perception  of  the  outlying  portions 
of  the  visual  field,  the  examination  is  made  of  each  eye  separately,  the  oculist 
employing  an  instrument  known  as  a  perimeter,  which  consists  of  an  arc 
of  a  circle,  of  about  12  inches  radius.     The  eye  to  be  examined  is  at  the 


Fig.  150. — Diagram  of  perimetric  charts  of  visual  fields  for  white  (form  field). 

centre  of  the  circle,  and  fixed  steadfastly  upon  a  white  spot  upon  the  are. 
A  white  object  5  to  10  mm.  in  size  is  slowly  moved  along  the  arc,  from  its 
extremity  towards  the  fixed  spot,  until  it  comes  within  the  patient's  range 
of  vision,  and  the  point  recorded  at  which  the  object  is  first  seen.  The  arc 
is  moved  to  another  position,  and  this  is  continued  until  the  whole  circle  has 
been  tested.  The  record  of  the  usual  points  so  taken  is  recorded,  as  in 
Fig.  150.  As  will  be  seen,  the  outlines  of  the  visual  field  are  far  from  sym- 
metrical. Its  greatest  extent  is  on  the  temporal  side,  usually  about  90°,  on 
the  nasal  side  55°,  above  50°,  below  65°.  The  perimeter  is  not  absolutely 
necessary  to  make  out  gross  lesions  such  as  hemianopsia  or  extensive  contrac- 
tion of  the  field,  since  the  finger  carried  from  point  to  point,  as  the  patient 
gazes  into  the  examiner's  eye,  will  indicate  marked  departure  from  the 
normal  limits.  Accurate  examination  requires  the  services  of  the 
ophthalmologist. 

Gradual  failure  of  vision  apart  from  refractive  errors  is  seen  in  disease 
of  the  cornea,  in  cataract,  non-inflammatory  glaucoma,  atrophy  of  the  optic 
nerve,  and  various  forms  of  intra-ocular  disease.     Rapid  loss  of  sight  occurs 


EXAMINATION  OF  THE  EYE. 


383 


in  acute  glaucoma,  retinal  hemorrhages,  embolism  or  thrombus  of  the 
central  retinal  vessels,  oedema  of  the  retina,  cerebral  effusions,  metastatic 
disease  of  the  eye,  ptomaine  poisoning,  and  after  quinine,  wood  alcohol, 
and  other  toxic  agents.  In  every  instance  of  decrease  in  the  normal  acuity 
of  vision,  the  oculist  should  be  immediately  consulted. 

Cataract  affects  vision  in  proportion  to  the  degree  and  situation  of 
the  opacity.  It  appears  as  a  congenital  or  senile  condition,  in  connection 
with  disease  of  the  eyes,  in  diabetes,  in  traumatism,  and  with  many  con- 
stitutional disorders  that  influence  the  nourishment  of  the  lens  through  the 
nutrient  vessels  of  the  choroid  and  ciliary  body.  Cataract  has  been  mistaken 
for  non-inflammatory  glaucoma,  owing  to  the  greenish  reflex  of  the  lens  in 
the  latter  disease.     The  diagnosis  is  readily  made  with  the  ophthalmoscope. 

Second  Sight. — The  ability  of  persons  past  middle  life  to  lay  aside 
their  usual  convex  reading  glasses  and  read  the  finest  print  (so-called  second 
sight)  indicates  swelling  of  the  lens,  and  is  one  of  the  first  signs  of  cataract. 
Glycosuria  is  a  frequent  cause  of  cataract,  and  acquired  myopia  after  40 
years  of  age,  even  with  clear  crystalline  lens,  should  direct  attention  to 
the  possible  existence  of  diabetes. 

Acute  Glaucoma. — Recurring  attacks  of  blurred  vision,  the  obscura- 
tion lasting  from  a  few  minutes  to  an  hour  or  more,  when  associated  with 
halos  about  the  light  (iridescent  vision),  should  direct  attention  in  persons 
past  middle  life  to  the  possibility  of  an  oncoming  attack  of  acute  glaucoma. 
The  "glaucomatous  attack"  usually  occurs  at  night,  is  characterized  by 
severe  pain  in  the  head,  nausea  and  vomiting,  and  rapid  loss  of  sight. 
The  eyeball  is  intensely  congested,  the  pupil  dilated,  the  cornea  anaesthetic 
and  steamy,  and  the  globe  of  stony  hardness.  The  affection  should  not  be 
mistaken  for  a  "  cold  in  the 
eye,"  iritis,  or  neuralgia.  The 
rheumatic  and  gouty  diathesis 
is  a  possible  causative  factor. 

Alterations  in  the  Visual 
Field. — Changes  in  the  visual 
field,  as  evidenced  by  irregular 
or  concentric  narrowing  of  the 
normal  limits  for  form  and 
color,  the  presence  of  central 
or  peripheral  areas  of  lost  per- 
ception (scotoma),  or  transpo- 
sitions of  the  order  of  colors, 
is  seen  in  disease  of  the  retina, 
optic  nerve,  and  central  ner- 
vous system,  or  may  be  present 
in  purely  functional  neuroses. 

Amblyopia  and  amaurosis 
designate  defective  vision  due 
either  to  fund  ional  disturbance 

or  to  actual  disease  of  the  visual  apparatus,  without  gross  ophthalmoscopic 
changes,  although  the  latter  restriction  is  no1  always  adhered  to.  The 
affection  of  the  sighl    may  be  limited  to  central  vision,  include  the  whole 


GSEfN 

Biue. 


FlO.   151. — Diagram  of  form  and  color  fields  of  right  eye 


384  MEDICAL  DIAGNOSIS. 

or  only  part  of  the  visual  field,  or  be  only  for  form  or  for  color.  A 
number  of  congenital  forms  of  amblyopia  are  recognized — for  form,  as 
in  the  poor  vision  of  squint,  or  for  color,  as  in  color-blindness.  Partial  or 
complete  loss:  of  sight  may  be  due  to  irritations  affecting  the  fifth  nerve, 
severe  injuries  of  the  head,  auto-intoxication,  the  nephritis  of  the  eruptive 
fevers,  diabetes,  malaria,  rheumatism,  action  of  certain  drugs,  and  to  hys- 
terical manifestations. 

Sudden  transient  failure  of  vision  may  mean  merely  the  temporary 
giving  out  of  eyes  already  weakened  by  general  affections  or  too  persistent 
use.  In  the  so-called  "visual  aura"  of  migraine,  there  is  a  decided  blurring 
of  the  visual  field,  which  has  been  designated  as  amblyopia,  but  is  transitory, 
and  is  to  be  distinguished  from  the  permanent  functional  impairment  of 
sighi  included  in  the  term.  Dercum  regards  a  slight  degree  of  amblyopia, 
with  or  without  a  diminution  of  the  color  sense,  as  an  early  and  invaluable 
symptom  of  paresis  which  may  even  antedate  distinct  and  demonstrable 
anomalies  of  the  pupils  or  changes  in  the  eye-grounds.  Transient  blindness, 
persisting  for  a  few  minutes  to  several  hours  or  days,  may  be  due  to  spasm 
of  the  retinal  arteries.  The  diminution  in  the  calibre  of  the  vessels  has 
been  observed  in  epilepsy,  migraine,  cold  stage  of  malarial  fever,  and  in  some 
toxic  conditions.  In  uraemia,  particularly  in  the  nephritis  of  scarlet  fever 
and  of  pregnancy,  the  sudden  loss  of  sight  may  be  associated  with  convul- 
sions, coma,  and  other  cerebral  symptoms.  Although  the  blindness  may  be 
complete,  the  reactions  of  the  pupils  are  usually  preserved. 

Amblyopia  from  Loss  op  Blood. — Amblyopia,  with  subsequent  complete 
atrophy  of  the  optic  nerve,  may  follow  profuse  spontaneous  hemorrhages 
from  the  stomach,  intestines,  uterus,  or  nasal  cavity.  The  loss  of  sight  may 
not  appear  for  a  week  or  more  after  the  bleeding,  being  due,  as  shown  by 
Holden,  to  degeneration  of  the  ganglionic  cells  of  the  retina  from  impaired 
nutrition. 

Methyl-alcohol  Amblyopl\. — Rapid  loss  of  sight  may  follow  the  drink- 
ing of  wood  alcohol  in  its  crude  or  purified  state,  or  when  employed  as  an 
adulterant  in  the  manufacture  of  Jamaica  ginger,  impure  whiskey,  cheap 
essences,  bay  rum,  and  other  alcoholic  beverages.  The  eye  symptoms  are 
often  associated  with  vomiting  and  purging,  severe  headache,  and  intense 
weakness.  The  vision  may  improve  for  a  few  hours  or  days  to  again  relapse, 
often  ending  in  complete  blindness.  The  symptoms  of  poisoning  may  follow 
inhalation  of  the  alcohol  by  workmen  in  mixing  varnishes,  shellacking  beer 
vats,  or  even  when  the  alcohol  is  applied  locally. 

Quinine  Amblyopia. — Quinine  affects  both  the  optic  nerve  and  retina. 
Usually  the  symptoms  follow  a  large  dose  of  the  drug,  but  a  moderate  amount 
has  been  followed  by  transient  visual  disturbances.  Following  a  toxic  dose 
there  is  usually  complete  blindness,  which  continues  for  a  few  hours,  days  or 
weeks.  Central  vision  at  first  returns,  with  gradual  enlargement  of  the 
peripheral  field,  but  the  latter  may  remain  permanently  contracted.  The 
ophthalmoscope  shows  cloudiness  of  the  retina,  contraction  of  the  vessels,  and 
pallor  of  the  optic  nerve.  Ethylhydrocuprein,  a  quinine  derivative,  employed 
in  the  treatment  of  pneumonia,  has  been  followed  by  symptoms  of  quinine 
poisoning.  Felix  mas  and  salicylic  acid  have  caused  visual  disturbances 
similar  to  those  of  quinine.    Nitrobenzole,  anilin,  iodoform,  and  thyroidine 


EXAMINATION  OF  THE  EYE.  385 

effect  the  visual  apparatus  when  taken  in  large  doses.  To  this  list  may  be 
added  lead,  tobacco,  atoxyl,  iodoform,  osmic  acid,  chloral  and  many  other 
drugs  used  in  medicine. 

Central  Amblyopia  (Retrobulbar  Neuritis). — The  orbital  portion 
of  the  optic  nerve  is  subject  to  interstitial  inflammation  in  either  an  acute 
or  chronic  form.  In  both,  the  disease  affects  those  portions  of  the  nerve 
that  supply  the  macular  region.  The  early  symptoms  are  dimness  of  vision, 
without  marked  ophthalmoscopic  changes,  and  a  weakness  or  loss  of  color 
perception  in  the  central  visual  field. 

In  retrobulbar  inflammations  the  visual  acuity  is  less  in  very  bright 
light,  and  exposure  to  excessive  light  may  lead  to  deterioration  of  vision 
that  may  last  for  some  time.  This  is  due  to  the  slowness  with  which  the  ill- 
nourished  axis-cylinders  are  regenerated.  There  is  also  a  close  relationship 
between  retrobulbar  disease  and  affections  of  the  seventh  nerve,  since 
paralysis  of  the  facial  nerve  may  precede  the  optic-nerve  inflammation.  In 
acute  retrobulbar  nt  uritis  there  is  rapid  failure  of  vision  with  central  or 
paracentral  scotoma,  which  is  usually  followed  by  recovery  of  vision, 
although  the  optic  disk  still  shows  pallor.  The  affection  may,  however, 
rapidly  progress  until  the  entire  nerve  is  implicated,  and  vision  is  nearly 
if  not  completely  lost.  The  disease  may  arise  during  the  course  of  rheuma- 
tism, gout,  diabetes,  smallpox,  and  other  toxaemias,  or  may  follow  orbital 
or  sinus  disease,  menstrual  suppression,  alcohol  or  lead  intoxication ;  and 
occasionally  is  found  in  insular  sclerosis  and  myelitis. 

In  chronic  retrobulbar  neuritis  there  exists  with  dimness  of  vision  a 
small  central  color  scotoma,  particularly  for  red  and  green,  the  horizontal 
oval  area  in  the  visual  field  extending  from  the  fixing  point  to  the  blind 
spot.  The  affection  is  found  principally  in  persons  using  large  quantities 
of  tobacco,  especially  when  combined  with  the  use  of  alcohol.  It  is  most 
frequently  noted  between  40  and  50  years  of  age,  and  has  also  been  found 
in  alcoholics  who  are  not  users  of  tobacco,  and  from  toxaemia  of  lead,  cannabis 
indica,  stramonium,  chloral,  carbon  bisulphide,  iodoform,  etc.  The  disturb- 
ance of  vision  is  greater  for  near  objects,  and  is  more  marked  in  bright  light. 

A  form  of  retrobulbar  neuritis  similar  to  that  of  toxic  origin  appears 
as  an  hereditary  affection,  and  is  referred  to  as  hereditary  optk  neuritis. 
It  affects  several  members  of  a  family,  especially  the  males,  and  has  been 
traced  through  several  generations.  The  optic  nerves  show  distinct  pallor. 
Vision  is  reduced  by  a  permanent  central  scotoma. 

Hemianopsia  (hemianopia)  is  a  loss  of  one-half  of  the  visual  field  of 
one  or  both  eyes,  due  to  a- lesion  in  the  optic  chiasm,  along  the  optic  tracts, 
or  in  the  visual  centres  in  the  occipital  lobe.  It  does  not  include  defects 
in  the  field  caused  by  disease  within  the  eyeball.  The  line  dividing  the 
seeing  from  the  blind  field  is  horizontal  or  vertical,  or  nearly  so,  and  may 
cut  exactly  through  the  fixing  point,  or  circumscribe  this  point  by  a  small 
zone  of  preserved  vision.     (Se&Fig.  387,  p.  733,  Vol.  II.) 

The  dividing  line  may  have  an  oblique  direction,  but  this  is  extremely 
rare,  or  only  a  sector,  commonly  a  quadrant,  of  the  field  may  be  wanting. 

Hemianopsia  is  classified  according  to  the  relative  position  of  the  blind 
portions  of  the  two  fields.  It  is  homonymous  if  there  is  loss  in  the  correspond- 
ing halves  of  each  field:  bitemporal  if  both  temporal  fields  are  blind,  and 

25 


386 


MEDICAL  DIAGNOSIS: 


binasal  when  the  nasal  halves  are  lost.  When  the  dividing  line  between  the 
lost  and  preserved  field  is  vertical,  the  defect  is  known  as  vertical  hemi- 
anopsia, and  when  the  dividing  line  is  horizontal,  the  hemianopsia  is  hori- 
zontal or  altitudinal. 

Homonymous  hemianopsia  is  the  commonest  form,  and  reveals  itself  as 
a  defect  in  the  right  or  left  half  of  each  visual  field.  For  instance,  in 
Fig.  152  the  left  half  of  each  field  is  wanting,  showing  loss  of  function  in  the 
right  half  of  each  retina.  If  the  right  half  of  each  field  is  lost  the  condition 
is  right  lateral  hemianopsia;  in  loss  of  the  left  half  of  each  field,  left  lateral 
hemianopsia.  The  seat  of  the  lesion  in  homonymous  lateral  hemianopsia 
is  in  any  part  of  the  visual  tract  between  the  chiasm  and  the  occipital  lobe. 
Bitemporal  hemianopsia  is  a  comparatively  rare  phenomenon,  but  one 
of  great  diagnostic  moment  when  found.    It  manifests  itself  as  a  blindness 


Fig.  152. — Diagram  of  perimetric  charts  of  right  lateral  hemianopsia.  The  dark  areas  show  loss 
of  the  nasal  half  of  left  and  temporal  half  of  right  fields,  with  contraction  of  the  preserved  fields.  The 
dividing  line  passes  around  fixing  point. 

of  the  outer  or  temporal  halves  of  the  visual  fields,  indicating  suspended 
function  of  the  nasal  portions  of  each  retina.  It  is  caused  by  a  lesion  which 
destroys  the  function  of  the  crossed  fibres  without  affecting  the  uncrossed 
fasciculi.  This  may  be  a  tumor,  fracture,  exostosis,  aneurism,  or  disease  of 
the  blood-vessels.  Loss  of  the  two  temporal  fields  is  seen  in  acromegaly, 
although  it  is  not  a  constant  symptom,  since  the  type  of  hemianopsia 
will  depend  upon  the  direction  the  pressure  is  exerted  upon  the  chiasm 
and  tracts. 

Binasal  hemianopsia,  in  which  both  the  nasal  fields  are  lost,  is  rare. 
If  it  is  true  that  the  crossed  and  uncrossed  fibres  of  the  optic  nerve  are 
mingled  at  the  outer  half  of  the  chiasm,  then  a  lesion  of  this  structure  cannot 
cause  binasal  hemianopsia.  Shoemaker  believes  that  this  defect  in  the  fields 
is  due  to  an  inflammation  of  the  optic  nerves. 

Both  upper  or  both  lower  fields  may  be  wanting.  In  this  condition,  the 
lesion  is,  as  a  rule,  at  the  chiasm,  encroaching  on  it  from  above  or  below. 

If  the  blind  halves  of  the  field  have  lost  not  only  perception  of  form 


EXAMINATION  OF  THE  EYE.  387 

and  light,  but  also  of  color,  the  defect  is  absolute;  if  only  recognition  of  color 
is  lost,  the  hemianopsia  is  relative. 

Hemianopsia  as  a  Diagnostic  Symptom. — In  lateral  hemianopsia  the 
intracranial  lesion  is  on  the  opposite  side  from  the  dark  fields.  If  unasso- 
ciated  with  motor  or  sensory  symptoms,  the  lesion  is  confined  to  the  cuneus, 
or  the  immediately  surrounding  gray  matter;  a  lesion  in  one  nerve  tract, 
or  in  the  primary  optic  centres,  with  symptoms  of  basal  disease,  would  cause 
changes  in  the  pupil,  and  possibly  some  affection  of  the  nerve  head  could  be 
recognized.  Hemiplegia  and  hemianesthesia  are  often  present  with  lateral 
hemianopsia,  indicating  organic  disease  of  the  brain,  the  lesion  being  situated 
in  the  internal  capsule.  If  right  hemiplegia  and  aphasia  are  associated  with 
lateral  hemianopsia,  an  extensive  lesion  probably  exists  of  the  area  supplied 
by  the  middle  cerebral  artery.  A  lesion  of  the  posterior  gray  matter  of  the 
optic  thalamus  could  produce  lateral  hemianopsia,  with  hemianesthesia  and 
ataxia  of  one  side  of  body.  A  cortical  lesion  is  usually  associated  with  con- 
centric contraction  of  the  preserved  fields,  or  is  found  in  cases  in  which  the 
light  sense  is  preserved,  but  the  color  or  form  sense  is  abolished. 

Hemianopic  Pupillary-inaction  Sign. — This  is  an  important  localiz- 
ing sign  in  hemianopsia,  and  consists  in  carefully  noting  if  the  pupil  reacts 
to  a  beam  of  light  thrown  upon  the  non-functionating  half  of  the  retina. 
It  is  an  extremely  delicate  test  to  make,  owing  to  the  difficulty  of  restricting 
the  beam  of  light  so  that  it  shall  illuminate  the  non-acting  half  of  the  retina 
without  allowing  any  light  to  fall  upon  the  seeing  half.  If  the  pupil  reacts 
when  the  light  is  thrown  upon  either  the  blind  or  the  seeing  half  of  the 
retina,  the  lesion  is  back  of  the  primary  optic  centres;  but  if  there  is  no 
reaction  when  the  light  falls  upon  the  blind  side,  but  the  pupil  reacts  when 
the  light  falls  upon  the  functionating  side,  the  lesion  is  in  front  of  the 
primary  optic  centres,  and  in  that  position  has  affected  the  motor  arc  of  the 
pupil.  The  test  should  always  be  made  in  a  well-darkened  room,  with  barely 
sufficient  light  to  conduct  the  examination,  and  should  be  confirmed  by  a 
second  observer  before  basing  a  diagnosis  on  its  apparent  presence.  Owing 
to  the  difficulty  of  absolutely  demonstrating  the  presence  of  the  reaction  it  is 
of  limited  value.  The  hemianopic  prism  phenomenon  of  Wilbrand  is 
regarded  by  many  observers  of  more  usefulness.  It  consists  of  placing  a 
strong  prism  before  one  eye,  so  that  the  image  of  a  small  piece  of  paper  on  a 
blackboard  is  thrown  upon  the  blind  half  of  the  retina.  The  observer  notes 
whether  the  eye  makes  a  compensators*  movement  when  the  prism  is  quickly 
placed  before  the  eye,  and  a  movement  in  the  opposite  direction  when  the 
prism  is  removed.    The  other  eye  is  baudaged  in  making  the  tests. 

Hysterical  Amaurosis. — The  diagnosis  of  visual  defects  due  to  hysteria 
is  sometimes  difficult,  although  healthy  eye-grounds  and  pupils  normally 
reacting  to  light  would  point  strongly  to  hysteria.  Cases  of  hysteric  blind- 
ness have  been  reported,  however,  in  which  light  failed  to  have  any  action 
on  the  pupil. 

If  unilateral  blindness  arises  suddenly,  following  fright,  emotional 
excitement,  slight  injury,  or  menstrual  pain,  hysteria  may  be  suspected. 
While  the  defect  may  be  bilateral,  it  is  more  often  unilateral.  It  is  not 
uncommon  to  find,  associated  with  the  ocular  symptoms,  other  disturbances  of 
sensation,  such  as  hemianesthesia  of  the  skin,  cornea,  or  conjunctiva.     If 


388  MEDICAL  DIAGNOSIS. 

the  amaurosis  is  restricted  to  one  eye,  under  some  conditions  it  may  be 
transferred  to  the  other  temporarily ;  and,  again,  the  unilateral  character 
of  the  affection  may  entirely  disappear  in  binocular  fixation,  as  proved  by 
the  diplopia  if  a  prism  of  sufficient  strength  to  prevent  normal  fusion  is 
placed  before  one  eye. 

Not  only  may  the  vision  be  reduced  in  hysteria,  but  changes  in  the 
peripheral  field  are  common.  The  contraction  in  the  field  is  usually  equal 
in  the  different  meridians,  and  is  often  of  the  tubular  type,  in  which  the 
limits  of  contraction  remain  the  same,  no  matter  what  distance  the  test 
object  is  removed  from  the  eye.  The  field  for  colors  likewise  shows  con- 
centric contraction,  or  the  limits  of  one  color  may  overlap  that  of  another, 
or  there  may  be  a  complete  reversal  of  the  colors.  In  some  instances  the 
so-called  fatigue  fields  are  found,  in  which  the  limits  constantly  change  dur- 
ing the  examination  or  vary  according  as  the  test  object  is  carried  from  the 
temporal  to  the  nasal  side,  or  vice  versa. 

Optic  Neuritis. — Inflammation  may  affect  the  optic  nerves  at  their 
intra-ocular  portions  (papillitis)  or  in  their  course  in  the  orbit  (retrobulbar 
neuritis) .  Under  the  term  hyperccmia  of  the  nerve  head  is  included  a  type  of 
optic-nerve  irritation  in  which  the  disks  become  of  dull  red  color,  the  surface 
and  margins  veiled,  and  the  lymph  sheaths  of  the  vessels  prominent.  It  is 
seen  in  refractive  error,  particularly  hyperopia  and  hyperopic  astigmatism, 
after  long-continued  exposure  to  intense  light  or  heat,  in  some  types  of 
inflammation  of  the  uveal  tract,  in  orbital  and  sinus  disease,  in  chronic 
insanity,  and  from  toxic  agents. 

Papillitis.  — Optic  neuritis  may  be  manifest  as  a  true  inflammation  of 
the  nerve  tissue,  a  swelling  of  the  intra-ocular  ending  of  the  optic  nerve,  or  as 
a  descending  neuritis.  The  changes  in  the  optic-nerve  head  may  range 
from  a  decided  redness,  moderate  swelling,  and  blurring  of  the  margins,  to 
an  intense  rounded  protrusion  of  the  disk  from  inflammatory  exudation,  red- 
dish gray  in  color  and  sloping  down  into  the  surrounding  retina,  the  retinal 
arteries  shrunken,  and  the  veins  full  and  tortuous  and  covered  in  by  infil- 
tration or  ending  in  numerous  hemorrhages.  Upon  subsidence  of  the  inflam- 
mation the  nerve  head  becomes  grayish  white  in  color,  the  oedema  subsides, 
and  the  extent  to  which  the  pressure  has  affected  the  nerve-fibres  is  shown 
by  the  degree  of  optic  atrophy  that  follows. 

A  moderate  degree  of  papillitis,  associated  with  hemorrhages  through- 
out the  retina,  few  changes  in  the  vessels,  and  spots  of  fatty  degeneration 
of  the  retinal  elements,  is  described  as  neuroretinitis,  and  is  the  type  most 
frequently  found  in  association  with  renal  disease.  The  intense  swelling  of 
the  papilla,  with  exudation  and  tortuosity  of  the  veins,  is  termed  choked  dish 
or  papillcedema,  and  is  the  usual  type  found  in  certain  forms  of  brain  tumor. 

The  neuritis  may  be  due  to  affections  of  the  orbit,  such  as  fracture, 
orbital  tumors,  purulent  cellulitis,  and  sinus  disease.  Intracranial  causes 
are  tumors,  syphilis,  abscess,  and  meningitis.  Tumors  of  the  brain  cause 
about  eighty  per  cent,  of  the  cases  of  choked  disk,  with  cerebral  syphilis  about 
ten  per  cent. 

The  situation  of  the  intracranial  portion  of  the  optic  nerve  tracts  at 
the  base  of  the  brain  renders  them  particularly  liable  to  implication  in  in- 
flammations of  the  basal  portion  of  the  meninges  and  to  the  pressure  of 


EXAMINATION  OF  THE  EYE.  389 

tumors  and  abscesses.  In  children,  tubercular  meningitis  is  usually  accom- 
panied by  swelling  of  the  optic  disk.  The  absence  of  affections  of  the  optic 
nerve  does  not  preclude  the  presence  of  a  new  growth  in  the  brain,  although 
when  the  base,  and  particularly  the  cerebellum,  is  the  seat  of  a  neoplasm, 
swelling  of  the  optic  disk  is  almost  always  present.  Double  optic  neuritis  of 
high  degree,  rapidly  progressive,  and  accompanied  by  marked  exudation  in 
the  nerve  and  surrounding  retina,  usually  indicates  a  tumor  of  the  cere- 
bellum, while  one  of  slower  growth,  less  intense,  and  either  unilateral  or 
considerably  greater  on  one  side  than  on  the  other,  is  seen  in  neoplasms  of 
the  cerebrum.  In  about  one-third  of  all  the  cases  there  is  associated  palsy 
of  the  ocular  muscles,  usually  the  sixth  or  third  nerves,  but  these  palsies 
occur  more  frequently  in  brain  syphilis  than  in  brain  tumor. 

The  "stellate  figure"  in  the  macula,  which  is  seen  in  a  large  proportion 
of  the  cases  of  renal  retinitis,  is  not  uncommon  in  the  intense  papillitis  of 
brain  tumor.  Tumors  or  abscesses  of  the  frontal  region  or  those  arising  from 
the  meningitis  rarely  cause  optic  neuritis,  although  swelling  of  the  optic 
disk  may  occur.  A  growth  in  the  pituitary  region  may  cause  inflammation 
of  the  optic  nerves,  but  it  is  more  frequent  to  find  simple  atrophy. 

Apart  from  the  intracranial  causes,  optic  neuritis  may  occur  from 
general  infections.  These  are  in  the  nature  of  a  toxin,  occurring  in  such 
diseases  as  influenza,  syphilis,  malaria,  rheumatism,  erysipelas,  and  many  of 
the  exanthematous  and,  continued  fevers.  Lead  and  alcohol  may  also  cause 
inflammation  of  the  optic  nerve,  and  the  same  process  is  seen  in  amemia, 
loss  of  blood,  sunstroke,  and  after  violent  exertion.  Syphilis  may  cause  a 
primary  neuritis  or  act  secondarily  through  gumma  of  the  brain  or  meninges. 

Unilateral  optic  neuritis  may  be  due  to  orbital  or  sinus  disease,  and  in 
rare  instances  to  cerebral  tumor,  in  which  the  neuritis  occurs  on  the  side 
of  the  neoplasm.  The  inflammation  of  the  retina  and  optic  nerve  of  nephritis 
and  certain  constitutional  disorders  is  often  unilateral,  but  with  the  progress 
of  the  systemic  disease  the  inflammation  attacks  the  other  eye. 

Central  vision  is  usually  unimpaired  even  in  intense  papillitis  during 
the  acute  stage,  and  if  defects  in  vision  occur  they  partake  of  the  nature  of 
defects  in  the  visual  field — an  enlargement  of  the  blind  spot,  concentric  con- 
traction, and  inversion  of  the  color  fields,  the  latter  occasionally  preceding 
changes  in  the  optic  nerve. 

Retrobulbar  neuritis  has  been  considered  under  Amblyopia. 

Optic=nerve  Atrophy. — Degeneration  and  atrophy  of  the  optic  nerves 
may  be  primary,  when  there  has  been  no  previous  inflammation  or  swelling 
of  the  papilla,  or  secondary,  if  preceded  by  previous  optic  neuritis  or  due 
fo  affections  of  the  retina  and  choroid.  In  both  forms  there  are  changes  in 
the  color  of  the  disk,  varying  from  a  gray  to  grayish  white,  with  the  edges 
usually  clear  and  distinct  in  the  primary  forms,  but  veiled  in  the  secondary. 

Primary  atrophy  is  more  frequently  associated  with  spinal  disease, 
particularly  locomotor  ataxia,  in  which  it  usually  appears  before  the  ataxic 
symptoms.  If  is  also  found  in  insular  sclerosis,  paralysis  of  the  insane,  and 
occasionally  in  lateral  Bclerosis.  It  may  occur  as  ;i  result  of  excessive  hemor- 
rhage from  the  stomach,  uterus,  or  intestines,  in  the  toxaemia  of  fevers,  alcohol 
or  lead  poisoning,  in  chronic  malaria,  syphilis,  and  diabetes,  in  fractures  of 
the  base,  and  in  deformities  of  the  skull.     Hereditary  optic-nerve  atrophy 


390  MEDICAL  DIAGNOSIS. 

appears  in  early  adult  life,  with  a  short  interval  between  the  involvement  of 
the  second  eye.  After  several  months  the  optic  nerve  shows  distinct  pallor, 
with  most  frequently  a  permanent  central  scotoma. 

Secondary  or  Consecutive  Atrophy. — The  contracted  retinal  arteries,  the 
dilated  and  tortuous  veins,  and  the  veiling  of  the  surface  and  edges  of  the 
optic  nerve  point  to  a  previous  papillitis.  Extensive  retinal  and  choroidal 
disease  also  results  in  atrophy  of  the  nerve,  as  will  pressure  upon  the  nerve- 
fibres  by  an  aneurism,  tumor,  or  exostosis. 

Retinitis. — The  retina  is  implicated  in  disease  affecting  the  intra-ocular 
end  of  the  optic  nerve,  and  also  from  extension  of  disease  from  the  ciliary 
body  and  choroid.  The  inflammation  is  associated  with  oedema  and  exuda- 
tion, reduction  of  vision,  especially  under  reduced  illumination,  hemorrhages 
cither  in  the  fibre  layer  or  deeper,  small-cell  infiltration,  and  tortuosity  of 
the  retinal  vessels,  with  changes  in  their  calibre.  Congenital  tortuosity  of 
the  retinal  vessels,  especially  of  the  veins,  is  frequently  seen.  In  individuals 
with  congenital  heart  lesions  the  retinal  veins  are  often  dilated  and  tortuous, 
and  the  arteries  are  nearly  as  dark  in  color  as  the  veins.  Small  hemorrhages 
may  be  found  near  the  optic  nerve  or  in  the  macula. 

Retinitis,  like  iritis  and  irido-cyclitis,  may  be  considered  in  the  majority 
of  instances  as  a  manifestation  of  some  toxic  process,  such  as  is  seen  in  many 
constitutional  disorders,  alterations  in  the  condition  of  the  blood  and  vessels, 
and  infections.  It  may  follow  extension  from  other  ocular  structures.  It 
is  often  divided  for  study  as  to  etiology  into  syphilitic,  diabetic,  renal, 
traumatic,  hemorrhagic,  etc. 

Syphilitic  Retinitis. — The  most  common  form  of  inflammation  is 
associated  with  proliferation  of  the  pigment  layer,  with  marked  changes  in 
the  choroid,  and  is  associated  with  reduced  vision,  dust-like  opacities  in  the 
vitreous,  and  night  blindness.  Hereditary  syphilitic  affections  are  seen  in 
diffuse  or  circumscribed  patches  of  retinal  and  choroidal  atrophy  with  some 
pigmentation. 

Diabetic  Retinitis. — The  small  white  dots  with  hemorrhages  in  the 
region  of  the  macula  and  towards  the  optic  nerve  from  the  macula  is  the 
more  frequent  form.  In  some  cases  there  are  extensive  areas  of  fatty  de- 
generation with  yellowish  exudation  in  the  region  of  the  macula,  with  smaller 
areas  and  hemorrhages  scattered  through  the  retina.  Both  eyes  are  affected, 
sometimes  with  an  interval  between. 

Albuminuric  Retinitis. — The  early  changes  appear  as  sAvollen  and 
tortuous  capillaries,  congestion  of  the  nerve  head  as  indicated  by  a  change 
in  its  color,  with  later  the  appearance  of  small  round  whitish  dots  and  hemor- 
rhages in  the  macula.  The  typical  star-shaped  figure  is  not  always  present. 
Usually  both  eyes  are  affected,  but  the  signs  of  congestion  and  oedema  may 
for  a  time  only  be  in  one  eye,  with  implication  of  the  other  eye  at  a  subse- 
quent date.  The  above  appearances  are  not  found  in  every  case  of  chronic 
renal  disease,  and  probably  not  more  than  one-fourth  of  the  cases  of  chronic 
renal  disease  exhibit  nerve  and  retinal  changes.  The  ophthalmoscopic 
pictures  seen  in  pregnancy  are  similar  to  those  mentioned  above,  and  are 
due  to  the  same  toxins  that  produce  the  lesions  in  chronic  renal  disease.  The 
differentiated  diagnosis^  between  the  fundus  changes  in  intracranial  disease 
and  kidney  affections  must  be  determined  by  other  factors,  including  the 


EXAMINATION  OF  THE  EYE.  391 

urine  examination  and  general  symptoms.  The  swelling  of  the  optic  nerve 
and  the  exudation  are  more  intense  in  brain  affections. 

Retinal  Hemorrhages. — Extravasation  of  blood  into  the  retina  may 
occur  independently  of  any  inflammation  of  the  retina.  It  is  usually  the 
evidence  of  extensive  vascular  disease,  or  of  organic  heart  affections.  It 
occurs  in  the  type  of  neuroretinitis  associated  with  chronic  nephritis,  dia- 
betes, and  general  arteriosclerosis ;  also  in  scurvy,  purpura,  polycythemia, 
marked  ana?mia,  in  the  new-born  suppressed  menstruation,  and  in  compres- 
sion of  the  thorax.  Embolism  or  thrombosis  is  associated  with  extensive 
hemorrhages  from  the  retinal  vessels.  Retinitis  with  hemorrhages  resembling 
those  seen  in  renal  disease  are  often  present  in  simple  ana?mia  and  chlorosis. 
The  position  and  extent  of  the  hemorrhage  determines  the  effect  on  vision. 

Obstruction  of  the  Retinal  Vessels. — An  embolism  of  the  central 
artery  of  the  retina  is  regarded  as  of  rare  occurrence,  the  general  symptoms 
of  occlusion  of  the  artery  or  its  branches  being  secondary  to  thrombosis  or 
to  obliterating  disease  of  the  walls  of  the  vessel.  Sudden  blindness  follows 
complete  obstruction  of  the  central  vessel,  whereas  in  plugging  of  one  of  the 
smaller  vessels  the  blind  area  will  correspond  to  the  section  of  the  retina 
supplied  by  the  vessel  affected.  Prior  to  the  attack  there  may  have  been 
periods  of  blurred  vision  for  a  considerable  period,  due  to  spasm  of  the  retinal 
vessels.  The  fundus  picture  in  embolism  of  the  central  artery  shows  a  pallid 
disk,  great  contraction  of  the  arteries,  a  clouding  of  the  retina,  and  the 
appearance  of  a  central  red  spot  in  the  fovea.  The  affection  is  seen  in 
valvular  cardiac  lesions,  in  endarteritis,  and  changes  in  the  composition  of 
the  blood,  although  in  about  one-third  of  the  recorded  cases  no  cause  could 
be  found,  the  patients  being  in  good  health  and  later  show  no  evidence  of 
organic  disease.  A  large  proportion  of  those  affected  were  females  under 
thirty  years  of  age. 

Thrombosis  of  the  central  retinal  vein  is  accompanied  by  rapid  reduction 
in  the  vision  until  only  the  ability  to  count  fingers  at  a  few  feet  is  preserved, 
with  the  ophthalmoscopic  picture  of  large  hemorrhages  with  later  yellowish- 
white  areas  between  them.  In  incomplete  obstruction  the  disturbance  of 
vision  depends  upon  the  extent  of  the  involved  retina.  Secondary  glaucoma 
is  a  frequent  complication,  requiring  enucleation  of  the  eyeball,  as  the  disease 
i>  not  favorably  influenced  by  the  usual  forms  of  treatment  by  miotics  or 
iridectomy. 

Retinal  Detachment. — Separation  of  the  retina  is  seen  in  high  degrees 
lit'  myopia,  following  traumatism,  effusion  of  blood  or  exudation  beneath  the 
retina,  and  from  growths  of  the  choroid.  The  detachment,  which  may  follow 
direct  injury,  sudden  strain  as  in  vomiting,  coughing,  or  lifting  heavy 
objects,  is  sudden,  and  is  accompanied  with  sudden  loss  of  vision  in  that 
portion  of  the  field  of  vision  opposite  to  the  detached  area.  In  instances  of 
slowly  formed  detachment,  the  vitreous  becomes  fluid  and  tilled  with  floating 
opacities.  The  diagnosis  of  detachment  is  readily  made  with  the  ophthalmo- 
scope, especially  if  the  separation  is  of  Large  size,  the  separated  retina  being 
thrown  in   Folds  of  pearly  Lrray  color,  over  which  the  retinal  vessels  pass. 

Arteriosclerosis.-  A  study  of  the  changes  in  the  retinal  blood-vessels 
is  of  extreme  importance  as  bearing  on  the  early  diagnosis  of  vat-inns  phases 
of  general  arteriosclerosis.     The  early  alterations  in  the  retinal  circulation 


392  MEDICAL  DIAGNOSIS. 

which  should  direct  attention  to  general  symptoms  indicative  of  beginning 
sclerotic  changes  are  tortuosity  of  one  or  more  of  the  smaller  arteries,  the 
evidence  of  undue  pressure  of  an  artery  at  its  point  of  crossing  of  a  retinal 
vein,  an  increase  of  the  light  reflex  of  the  arteries,  and  irregularity  of  the 
calibre  of  the  veins.  At  first  the  vein  is  simply  displaced  in  the  direction 
of  the  arterial  circulation,  and  its  flow  slightly  obstructed ;  later  the  venous 
current  is  markedly  impeded,  and  the  vein  greatly  narrowed  where  the 
arterial  pressure  is  exerted,  and  is  distended  on  the  peripheral  side.  These 
changes  are  rarely  accompanied  by  sufficient  fibrous  thickening  to  cause  white 
lines  of  perivascular  inflammation  along  the  vessel.  As  the  vessel  walls  lose 
their  elasticity,  the  impediment  to  the  flow  of  blood  results  in  tortuous  ves- 
sels, the  escape  of  fluid  into  the  surrounding  tissues,  and  retinal  oedema. 
These  conditions,  are  not  due  to  old  age  only,  but  to  actual  sclerosis  of  the 
vessels  from  disease.  These  early  changes  are  difficult  to  diagnose  except 
by  a  skilful  observer. 

The  importance  of  early  recognition  of  these  ocular  changes  lies  in  their 
association  with  similar  disease  of  the  brain  and  kidney.  There  is  no  diffi- 
culty in  determining  by  the  ophthalmoscope  the  evidence  in  the  eye-ground 
of  well-advanced  types  of  arteriosclerosis,  but  it  is  important  that  recognition 
of  these  signs  should  be  made  before  the  disease  has  reached  a  point  where 
treatment  is  ineffectual.  De  Schweinitz  called  especial  attention  to  the 
value  of  early  recognition  of  the  signs,  even  though  they  be  only  suggestive 
of  angiosclerosis  of  the  retinal  vessels  in  persons  who  have  reached  the  age 
at  which  vessel  degeneration  may  begin  to  appear,  and  who  consult  the  oph- 
thalmologist for  a  change  of  reading  glasses.  These  signs  are  "a  corkscrew 
appearance  of  individual  vessels,  a  slight  thickening  of  the  perivascular 
lymph  sheaths,  a  beginning  brick-dust  appearance  of  the  optic  nerve-head, 
and  a  flattening  of  a  vein  against  an  artery  or  a  bending  in  a  curve  of  the 
vein  overlying  the  artery."  With  these  retinal  conditions  present  the  phy- 
sician should  carefully  examine  the  cardiovascular  system,  and  accurately 
test  the  arterial  tension  by  approved  means,  and,  should  the  tests  confirm 
the  retinal  findings,  institute  appropriate  treatment,  which  may  save  not 
only  lesions  of  the  eyes  but  of  other  structures,  notably  the  brain,  which, 
if  they  occur,  may  prove  fatal. 


PLATE  IX. 


[Changes  in-  Arteriosclerosis. — After  De  Schweiniti. 

A,  Normal  fundus.  B  to  F,  successive  changes  oocurring  in  artei  iosclerosis,  including  pallid  arteries 
(B),  later  assuming  :i  silver-wire  appearance  fC):  indented  veins  (B,  C),  afterward  showing  ampulliform 
enlargements  (D,  E);  corkscrew  capillaries  (C,  D):  corkscrew  arteries  and  veins  (D,  E)i  perivasculitis 
^C,  l>),  sclerosis  ol  vessels  (F);  wlumu  of  disk  I  B,  < '.  I),  E),  hemorrhages  (< ',  F). — D.] 


E  » 

[Chanoes  in  Retinal  Vessels.  —  After  Wordemann  in  Posey  and  Spiller. 
A,  Embolism  central  artery;  partial,  affecting  only  inferior  branch  (Haab).     B,  Bmbo 
artery-  total  within  nerve;  a  ciho-retinal  vessel  supplies  :i  small  area  of    retina  in  which    Function    is 
preserved  f  WOrdemann) .    C,  Thromboeia  of  central  vessels  from  mumps  <  w  urdemann).     D,   Sai 
m\  months  later,  showing  sclerosis  and  atrophy  (Wttrdemann).     E,  Hemorrhages   from  retinal 
(Magnus       F,  Perivasculitis  luetica  (Magnus).  — D.] 


[Inki.amm  \ noire  of  tiik   Retina, — After  Wurdemann  in  Posey'andTSpiller. 

\,  (Edema  in  pernicious  anemia  (Oliver).  B,  Leucsmic  retinitis  (Oliver).  Ci  Albuminuric  retinitis 
and  neuritis  of  pregnancy  (WQrdemann).  I).  Albuminuric  retinitis  in  the  negro  (Wtirdemann).  E, 
Syphilitic  retinitis  (ll;i:ili).  K,  Atrophy  of  retina,  chorioid,  and  nerve  Following  chorio-retinitis  luetics 
(Oeller.)     I).] 


EXAMINATION  BY  MEANS  OF  RONTGEN  RAYS.    393 

XI 
EXAMINATION  BY  MEANS  OF  RONTGEN  RAYS.1 

Rontgen  made  his  discovery  in  1895.  It  was  a  new  kind  of  energy,  its 
true  nature  unknown,  hence  he  termed  it  X-ray.  Within  a  month  from  the 
time  of  his  discovery  he  disclosed  three  facts  which  have  made  these  rays 
the  most  important  diagnostic  agent  in  the  field  of  medicine,  viz.,  that  they 
penetrate  all  objects  to  a  degree  somewhat  in  direct  proportion  to  the  atomic 
density  of  the  object;  that  they  have  actinic  properties  similar  to  ordinary 
light  in  their  action  on  photographic  plates;  and  that  they  excite  fluorescence 
in  certain  substances,  notably  barium  platinocyanide  and  tungstate  of  cal- 
cium. For  example,  the  rays  will  penetrate  all  of  the  structures  of  the  hand, 
but  they  will  pass  through  the  soft  parts  more  freely  than  through  the  bony 
parts;  therefore,  if  the  rays  after  passing  through  the  hand  are  permitted  to 
act  upon  a  photographic  plate,  which  is  protected  from  other  forms  of  light, 
the  various  portions  of  the  hand  will  record  their  respective  densities,  and 
after  the  process  of  development  the  plate  will  become  a  permanent  record 
of  shadows,  appreciable  to  the  naked  eye.  Such  a  record  is  termed  a  skia- 
gram, a  radiogram,  or  preferably  a  rontgenogram.  If  a  screen  covered  with 
an  emulsion  containing  crystals  of  barium  platinocyanide  or  tungstate  of 
calcium  be  substituted  for  the  photographic  plate,  and  other  forms  of  light 
be  excluded,  the  Rontgen  rays,  in  passing  through  the  hand,  will  be  obstructed 
according  to  the  density  of  the  various  parts  of  the  hand  and  one  will  see 
immediately  the  shadows  on  the  fluorescent  screen.  Such  a  screen  is  known 
as  a  fluoroscope,  or,  better,  a  rontgenoscope.  All  Rontgen-ray  examinations, 
then,  are  made  by  means  of  rontgenograms,  or  by  means  of  the  rontgeno- 
scope. The  diagnostic  value  of  such  examinations  depends  directly  upon 
the  technic  and  interpretative  skill  of  the  rontgenologist.  In  the  hands  of 
the  inexperienced  and  untaught  the  results  are  often  valueless  or  misleading; 
and,  because  of  the  modern  powerful  exciting  apparatus,  the  patient  is  in 
danger  of  being  injured. 

The  rontgenographic  method  of  examination  has  a  far  wider  field  of 
usefulness  than  the  rontgenoscopic.  The  rontgenogram  is  a  permanent 
record,  can  be  studied  indefinitely,  and  shows  much  finer  detail  in  shadows 
than  can  be  seen  by  means  of  the  rontgenoscope.  The  former  is  applicable 
to  all  parts  of  the  body,  whereas  the  latter  has  advantages  only  in  the  study 
of  movable  organs — e.g.,  the  thoracic  viscera  and  the  gastro-intestinal  tract. 
Rontgenoscopic  examination  should  be  made  only  with  the  most  protective 
apparatus  and  continued  for  as  little  time  as  possible,  to  insure  safety  to 
operator  and  patient. 

Stereorontgenograms  give  accurate  depth  relations  and  are  most  useful. 
To  make  stereoscopic  rontgenograms  it  is  necessary  to  have  a  plate  holder 
which  will  permit  of  plates  being  inserted  and  removed  without  disturbing 
the  patient  or  the  X-ray  tube  holder.  Two  exposures  are  made,  the  focus 
tube  being  displaced  two  and  one-half  inches  either  laterally  or  longitudinally. 
All  modern  tube  holders  are  supplied  with  automatic  or  easily  adjusted  dis- 

1  Contributed  by  Professor  Menu"-  as  collaborator. 


394  MEDICAL    DIAGNOSIS. 

placement  device.  The  resultant  negatives  are  then  viewed  by  means  of  a 
stereoscope.  Reductions  may  be  made  from  the  original  negatives  and  viewed 
by  means  of  the  ordinary  hand  stereoscope. 

Examinations  of  the  head  should  always  be  made  stereorontgenographic- 
ally.  In  this  way  the  diagnosis  of  lesions  of  the  accessory  sinuses,  including 
the  mastoid  cells,  is  made  with  much  accuracy.  A  sinus  filled  with  pus  is 
more  nearly  opaque  to  the  rays  than  one  containing  air;  even  granulation 
tissue  or  retained  mucus  casts  shadows  distinguishable  from  the  normal. 
The  importance  of  this  procedure  becomes  apparent  when  one  considers  the 
frequency  of  sinus  or  mastoid  infection  as  complications  or  sequelae  to  the 
infectious  diseases.  Intracranial  lesions  are  shown  by  the  effect  they  produce 
on  the  inner  table  of  the  skull  or  the  sutures,  or,  if  they  possess  a  density 
greater  than  that  of  the  brain  substance,  by  the  presence  of  foreign  shadows. 
Any  localized  organic  lesion  of  the  cortex  of  the  brain  will  produce  changes 
in  the  inner  table  of  the  skull  either  by  way  of  bone  atrophy  due  to  increased 


Fig.  153. — Convolution  depressions  very  deep,  due  to  early  ossification  of  the  sutures  and  moderate  internal 
hydrocephalus.     Child  is  a  congenital  syphilitic. 

local  pressure  or  by  actual  destruction  of  bone  involved  in  the  disease  process. 
When  intracranial  pressure  is  increased  by  dilatation  of  the  ventricles  the 
convolutions  of  the  brain  soon  produce  impressions  on  the  inner  table  which 
show  clearly  on  the  rontgenogram,  and  in  the  cases  of  children  the  skull 
sutures  are  shown  to  be  more  separated  than  normal.  Acute  external  hydro- 
cephalus causes  the  sutures  to  separate,  but  even  the  normal  convolution 
impressions  are  absent.  Disorders  of  the  pituitary  are  manifested  by  some 
deviation  from  the  normal  in  the  rontgenographic  appearance  of  the  sella 
turcica.    Diseases  and  abnormalities  about  the  teeth  may  be  shown  clearly. 

The  thorax,  because  of  the  great  contrast  in  density  of  its  contained 
organs,  is  most  accessible  to  Rontgen-ray  study.  One  should  become  thor- 
oughly familiar  with  rontgenograms  of  many  normal  chests  before  attempting 
to  recognize  the  abnormal  unless  it  has  been  carefully  indicated  by  one  who 
is  skilled.  Only  in  this  way  is  it  possible  to  appreciate  the  very  early  deposits 
of  a  tuberculous  lesion  or  other  infiltrating  process,  a  thickening  of  the  pleura, 


EXAMINATION  BY  MEANS  OF  RONTGEN  RAYS. 


395 


inflammatory  thickening  or  dilatation  of  the  bronchial  tubes,  enlargement 
of  the  peribronchial  glands,  the  extent  of  lung  involvement,  the  presence  and 
extent  of  pneumothorax  or  of  pleural  effusion,  enlargement  of  the  thymus 
gland,  existence  of  substernal  goitre,  and  variations  from  the  normal  in  the 


Fig.  154a. — Enlarged  peribronchial  glands.      Lung  shadows  normal.     (Viewed  from  the  back.) 


size  and  contour  of  the  heart  and  large  blood-vessels.  Some  of  these  condi- 
tions are  diagnosed  positively  without  other  aid,  but  as  a  rule  careful  physical 
examination  and  clinical  study  are  essential  to  correct  differential  diagnosis. 
For  instance,  the  rontgenogram  of  enlarged  peribronchial  glands  does  not 


Fi<;.  154b. — Extensive  pneumothorax  on  lefl  Bide,  alight  displacement  of  heart.     (Viewed  from  back.) 

indicate  whether  the  enlargement  is  due  to  tuberculous  or  other  infection, 
and  a  history  of  measles,  influenza,  or  other  infectious  disease  is  sufficient 
to  limit  the  diagnostic  value  of  the  plate.  Again,  the  infiltration  of  syphilis 
has  much  the  same  rdntgenographic  appearance  as  tuberculous  infilt ration, 
and  so  instances  might  be  multiplied.     All  intrathoracic  conditions  except 


396 


MEDICAL    DIAGNOSIS. 


mediastinal  tumors,  lesions  of  the  circulatory  organs,  and  those  involving 
the  diaphragm  are  best  revealed  by  the  rontgenographic  method.  The 
presence  or  absence  of  pulsation,  and  the  excursus  of  the  diaphragm  can  only 


Fig.  155a. — Extensive  pleura    effusion  on  right  side,  very  little  displacement  of  heart 
of  upper  leve    of  fluid       (Viewed  from  back.) 


Notice  obliquity 


be  determined  by  means  of  the  rontgenoscope.  With  the  modern  apparatus 
one  can  make  a  tracing  which  shows  accurately  the  size  of  the  heart  and  its 
relations  to  other  structures,  the  size  and  extent  of  pulsation  of  an  aneurism, 


Fig.  1556. — Recurrent  sarcoma  of  chest  wall.     Notice  sharp  outline  of  growth.     (Viewed  from  back.) 

the  excursus  of  the  diaphragm,  etc.  The  size  of  the  heart  in  its  lateral  and 
vertical  dimensions  can  be  shown  on  a  rontgenogram  if  the  exposure  is  made 
with  the  tube  at  a  distance  of  seven  feet  or  more.  Such  a  picture  is  known 
as  a  telerontgenogram. 


EXAMINATION  BY  MEANS  OF  RONTGEN  RAYS. 


397 


Again,  stereorontgenograms  are  of  the  utmost  importance  in  the  study 
of  lung  lesions.  Only  in  this  way  can  one  determine  the  depth  and  true 
size  of  isolated  foci  of  disease  or  cavities.  The  earliest  possible  signs  of 
pulmonary  tuberculosis  are  minute  areas  of  infiltration  in  the  parenchyma 
and  a  matting  or  clumping  of  the  very  small  branches  of  the  bronchial 
tubes  or  bronchioles.  Even  in  the  normal  chest  these  fine  tubes  can  be  traced 
to  the  very  periphery  of  the  lung  if  the  rontgenograms  are  of  excellent  quality. 
The  stereoscope  enables  one  to  see  whether  they  proceed  to  the  periphery 
discretely  or  whether  they  are  matted  together  at  points.  The  two  plates 
must  be  exposed  and  interchanged  in  a  period  of  time  during  which  the  patient 
can  hold  a  full  inspiration  at  complete  rest.  The  tube  should  be  displaced 
parallel  to  the  longitudinal  axis  of  the  body.    The  patient  may  be  in  an  erect 


Fig.  156a.  —  Metastatic  sarcomata  of  both  lungs.     (Front  view.) 

or  horizontal  position,  but  exposures  should  be  made  from  both  front  and 
back.  The  erect  posture  has  the  advantage  in  that  a  lung  cavity  partly 
filled  with  pus  will  show  an  upper  level. 

Pneumothorax  is  readily  distinguished  from  every  other  condition  by 
the  complete  absence  of  lung  shadow  within  the  area  of  the  plate  covered  by 
the  air-containing  space.  Occasionally  pneumothorax  and  pleural  effusion 
coexist.  In  such  cases  the  examination  must  be  made  with  the  patient 
sitting  or  standing,  when  a  sharp  transverse  upper  level  of  dense  fluid  shadow 
will  be  seen  with  a  less  dense  pneumothorax  area  above  it.  On  fluoroscopic 
examination  waves  can  be  set  up  and  seen  in  the  upper  level  of  the  fluid  by 
percussing  the  chest  wall.  These  waves  cannot  be  produced  in  simple  pleural 
effusion,  and  the  upper  level  of  fluid  is  obliquely  downward  and  inward. 
Purulent  and  non-purulent  effusions  cannot  be  differentiated  by  means  of 
X-ray.     Encysted  effusions  are  determined  by  their  more  or  less  rounded 


398  MEDICAL    DIAGNOSIS. 

form  and  by  the  fact  that  gravity  does  not  determine  the  inferior  boundary. 
They  may  be  interlobar,  or  between  the  parietal  and  visceral  pleura. 

Localized  or  general  thickening  of  the  pleura  is  determined  by  compara- 
tive study  of  the  unaffected  portions,  the  thickened  areas  producing  shadows 
considerably  more  dense  than  normal  areas,  but  not  so  dense  as  an  area  of 
pleural  effusion. 

Rontgen-ray  examination  of  the  entire  alimentary  tract  is  made  possible 
by  the  ingestion  or  injection  of  a  substance  opaque  to  the  rays,  or  in  certain 
instances  the  introduction  of  air  which  permits  the  rays  to  pass  more  freely. 
Bismuth  oxy chloride,  bismuth  subcarbonate,  and  barium  sulphate  (specially 
prepared)  are  the  opaque  substances  in  general  use.  Here  the  rontgeno- 
scopic  method  is  essential. 

Diseases  of  the  oesophagus  are  distinguished  by  their  effect  upon  its 
lumen  and  course.     A  diverticulum  will  retain  a  portion  of  the  bismuth  and 


Fig.  156b. — Larger  aneurism  involving  ascending    transverse  and  descending  arch.     (Viewed  from  back.) 

cast  a  shadow  of  localized,  pocket-shaped  enlargement.  Organic  narrowing 
of  the  lumen  is  apt  to  be  irregular,  whereas  spasmodic  stricture  is  usually 
abrupt  and  smooth  in  outline.  The  former  is  constant,  the  latter  intermittent, 
relieved  by  antispasmodics,  and  not  accompanied  with  marked  loss  in  weight. 
The  oesophagus  is  best  seen  when  the  rays  pass  obliquely  through  the  chest. 
The  calibre  of  a  stricture  can  be  determined  by  having  the  opaque  mixture 
of  such  viscidity  that  it  will  pass  slowly  under  swallowing  pressure  from  above 
through  the  narrowed  portion. 

The  wide  variations  in  size,  shape,  position  and  relations  of  the  gastro- 
intestinal tract,  within  normal  limits,  make  the  Rontgen-ray  study  of  these 
organs  a  task  of  large  proportions.  The  variations  in  diseased  conditions 
are  even  greater,  and  then,  too,  the  stomach  is  reflexly  influenced  by  disease 
in  adjacent  organs.  Broadly  speaking,  the  normal  stomach  is  one  which  lies 
with  its  upper  two-thirds  in  the  upper  left  quadrant  of  the  abdomen,  with 
the  lower  third  crossing  the  median  line  so  that  the  pylorus  is  from  one-half 


EXAMINATION  BY  MEANS  OF  RONTGEN  RAYS. 


399 


to  two  inches  to  the  right  of  the  median  line,  and  above  the  level  of  the 
umbilicus.  The  greater  curvature  is  the  lowermost  portion,  extending  from 
the  level  of  the  umbilicus  to  two  inches  below  this  level.     It  fills  gradually 


Fig.  157a. — Small  particles  of  bismuth  in  the  lower  right  bronchial  tubes.     There  is  communication  with 

the  oesophagus  due  to  carcinoma. 

from  above  downward  so  that  the  entire  lesser  and  greater  curvatures  can  be 
seen  with  a  comparatively  small  quantity  of  opaque  meal  of  thick  fluid  con- 
sistency, and  enlarges  throughout  when  completely  filled,  the  posture  being 


Fio.  1576. — Organic  stricture  of  oesophagus.      Note  bismuth  in  dilated   portion  above  the   stricture    and 
irregularity  of  outline  nl  the  point  of  obstruction.     (Oblique  view.) 

erect.  The  peristaltic  waves  begin  at  the  junction  of  the  upper  and  middle 
thirds,  shallow  at  first,  but  become  deeper  as  they  approach  the  pylorus, 
where  they  end  in  the  closed  pylorus.  The  waves  recur  at  intervals  of  about 
twenty  seconds,  and  are  deeper  on  the  greater  curvature  than  on  the  lesser 


400  MEDICAL  DIAGNOSIS. 

curvature  until  they  approach  the  pylorus.  The  entire  opaque  meal  leaves 
the  stomach  in  from  four  to  six  hours. 

In  the  athletic  type  of  person  with  tense  muscular  abdominal  walls  the 
stomach  is  usually  high,  so  that  even  the  greater  curvature  is  from  one  to 
three  inches  above  the  level  of  the  umbilicus,  and  the  long  axis  becomes 
more  oblique  with  relation  to  the  long  axis  of  the  vertebrae.  The  peristaltic 
waves  are  proportionately  more  vigorous  and  the  emptying  time  less  than 
the  average  normal  stomach. 

The  opposite  of  this  type  of  normal  stomach  is  that  in  the  individual 
whose  abdominal  walls  are  weak  and  relaxed.  The  greater  curvature  reaches 
three  inches  below  the  level  of  the  umbilicus,  while  the  pylorus  is  at  or  a 


Fig    158a. — True  ptosis  of  stomach. 

little  above  the  level  of  the  umbilicus  and  more  nearly  in  the  median  line. 
The  peristaltic  waves  are  lessened  in  vigor  and  the  normal  emptying  time 
is  about  six  hours. 

When  the  greater  curvature  reaches  a  still  lower  level  it  is  due  either  to 
dilatation  or  extreme  atony,  and  the  pylorus  remains  at  the  normal  level, 
or,  if  it  is  to  be  considered  true  ptosis,  the  pylorus  is  at  a  lower  level  near  the 
median  line,  and  the  greater  curvature  may  extend  into  the  pelvis.  The 
ptotic  stomach  is  usually  more  or  less  dilated.  The  emptying  time  of  the 
dilated,  atonic,  or  ptotic  stomach  is  from  seven  hours  to  indefinite. 

Rontgen-ray  diagnosis  of  organic  gastro-intestinal  lesions  should  be 
based  very  largely  on  direct  evidence;  that  is,  the  defect  should  be  demon- 
strable either  on  the  fluoroscopic  screen  or  on  sensitive  plates,  and  often  both 
are  essential.  Functional  disorders  and  those  due  to  faulty  position  or  mus- 
culature require  fluoroscopic  study  combined  with  palpation.  Much  of  the 
evidence  is  direct,  but  indirect  evidence  is  also  of  great  importance  in  this 
class  of  conditions. 


EXAMINATION  BY  MEANS  OF  RONTGEN  RAYS.    401 

Ulcer  is  probably  the  most  common  of  the  organic  stomach  lesions. 
In  the  early  or  acute  stages  when  only  the  mucosa  is  involved  the  X-ray 
findings  are  largely  inferential.  Deep  spasmodic  contraction  is  seen  on  the 
greater  curvature,  making  a  sharp  incisure  in  the  shadow  of  the  opaque 
meal.  The  ulcer  is  usually  on  the  lesser  curvature  at  the  level  of  the  incisure. 
Incisure  may  occur  as  a  reflex  phenomenon,  but  will  relax  after  the  adminis- 
tration of  antispasmodic  drugs.  In  ulcer  cases  the  incisure  may  remain  for 
hours  or  recur  intermittently.  There  is  delay  in  emptying  the  stomach  due 
to  spasmodic  condition  of  the  pylorus.  There  is  no  point  of  tenderness,  but 
deep  pressure  may  excite  a  violent  contraction,  and  the  incisure  will  appear 
in  spite  of  antispasmodics. 

"When  an  ulcer  has  penetrated  the  mucous  and  muscular  coats  a  definite 
and  constant  deformity  occurs  in  the  shadow  of  the  filled  stomach.  The 
deformity  has  the  appearance  of  being  a  small  diverticulum.     Spasmodic 


Fig.  1586. — Marked  ptosis  of  colon.     Same  case  as  Fi«.  158a 

contractions  may  occur  opposite  the  ulcer,  but  are  not  constantly  associated. 
If  the  ulcer  has  healed  in  part  there  will  be  a  more  or  less  complete  "hour- 
glass" contraction.  The  peritoneal  coat  may  become  perforated,  and  then 
small  particles  of  the  opaque  meal  can  be  seen  isolated  from  the  stomach 
shadow,  and  there  is  usually  almost  complete  "hour-glass"  formation  due 
to  cicatricial  tissue  contraction.  There  is  usually  a  point  of  tenderness  in 
deep  ulcer.  When  ulcers  occur  near  the  pylorus  it  requires  Very  careful 
observation  to  detect  them  in  the  early  stages.  The  peristaltic  waves  on  the 
lesser  curvature  are  apt  not  to  reach  the  pylorus,  and  there  is  retention.  If 
the  ulcer  heals  partly  and  contracts  so  as  to  produce  mechanical  obstruction, 
retention  becomes  more  prominent  and  dilatation  of  the  stomach  follows. 
Vomiting  is  a  rarely-associated  symptom. 

Carcinoma  of  the  stomach  can  be  diagnosed  positively  only  when  of 
sufficient  extent  to  produce  a  permanent  defect  in  the  outline  of  the  stomach 
26 


402 


MEDICAL   DIAGNOSIS. 


shadow.  Then  the  distinguishing  feature  is  the  irregular  punched-out  ap- 
pearance of  the  defect.  Pyloric  spasm  is  not  present  and  the  stomach  empties 
more  rapidly  than  normal  if  the  pylorus  is  not  obstructed.  Vomiting  and 
loss  of  appetite  and  weight  are  common  symptoms  when  the  lesion  is  at  the 
pylorus,  and  hsematemesis  appears  when  the  mucosa  is  destroyed.  It  is 
surprising,  however,  to  what  extent  the  stomach  may  be  involved  before 
symptoms  appear  when  the  pylorus  is  not  involved. 

In  any  lesion  of  the  stomach  involving  the  peritoneal  layer  adhesions 
form  and  the  stomach  cannot  be  displaced  at  such  points  by  palpation. 

Reversed  peristalsis  is  occasionally  seen,  and  so  far  as  we  know  is  always 
associated  with  some  organic  lesion  of  the  stomach. 


Fig.  159. — Carcinoma  of  pyloric  end  of  stomach  three  hours  after  taking  opaque  meal.  Almost 
complete  obstruction  of  pylorus,  very  little  dilatation.  Exposure  made  obliquely  to  isolate  stomach  shadow 
from  spine. 

Pyloric  spasm  and  consequent  retention  occurs  reflexly  from  disease  in 
other  organs,  such  as  the  gall-bladder,  kidneys,  or  appendix.  In  such  cases 
further  X-ray  study  is  necessary,  particularly  during  deep  palpation. 

In  duodenal  ulcer  the  most  accepted  signs  are:  irregularity  in  outline 
of  first  portion  (where  the  vast  majority  occur);  marked  gastric  hyperperi- 
stalsis ;  rapid  emptying  of  the  stomach  during  the  first  hour  in  non-obstructive 
cases;  retention  of  bismuth  in  the  stomach  after  six  hours  in  obstructive  cases; 
fixation  of  duodenum  in  late  cases  or  in  gall-bladder  disease  with  adhesions 
to  the  duodenum ;  and  occasionally  sensitive  pressure  point  over  the  duodenum. 

In  the  intestines  obstructive  lesions  are  determined  by  the  presence  of 
dilatation  of  the  proximal  portion  and  delay  in  passage  of  the  bismuth. 
The  colon  is  to  be  studied  by  its  action  on  the  ingested  meal  as  well  as  by 
injection.  All  of  the  usual  chemical  tests  for  acidity,  blood,  etc.,  should  be 
made  prior  to  the  Rontgen-ray  examination,  as  they  sometimes  influence  the 
interpretation  of  certain  findings.  A  complete  clinical  history  is  also  an 
essential  adjunct. 

In  diseases  of  the  gastro-intestinal  tract  that  are  not  locally  destructive 


EXAMINATION  BY  MEANS  OF  RONTGEN  RAYS. 


403 


or  due  to  new  growth  the  Rontgen-ray  examination  is  of  value  in  confirming 
the  facts  of  relation  to  other  viscera,  and  not  infrequently  showing  lesions 
elsewhere  which  produce  symptoms  referable  to  the  stomach.    Kidney  stone 


Fig.  1G0. — Congenital  dilatation  of  the  colon.     (Viewed  from  back.) 

is  often  responsible  for  gastric  symptoms  which  mask  or  exceed  the  renal 
symptoms. 

Enlargement  of  the  liver  can  be  shown,  gall-stones  are  demonstrable 


Stone  i  n  right  kidney 


in  about  fifty  per  cent,  of  the  cases,  and  in  slender  patients  the  gall-bladder 
distended  so  that  it  projects  below  the  liver  can  occasionally  be  shown.  The 
size  of  the  spleen  can  be  determined,  especially  if  the  stomach  and  colon  be 
distended  with  air  or  gas. 


404  MEDICAL    DIAGNOSIS. 

The  urinary  organs  are  studied  by  means  of  the  rontgenographic  method 
only.  The  rontgenogram  should  show  enough  of  the  outline  of  both  kidneys 
to  establish  approximately  the  size  and  position  in  patients  of  one  hundred 
and  sixty-five  pounds  or  less.  This  is  due  to  the  fact  that  the  cortical  portion 
of  the  kidney  is  more  dense  than  surrounding  structures,  especially  in  the 
region  of  the  lower  poles.  The  pelves  of  the  kidneys,  the  ureters,  and  the 
bladder  do  not  cast  distinguishable  shadows.  However,  the  outline  of  the 
entire  urinary  tract  may  be  shown  on  th§  rontgenogram  after  the  injection 
of  a  solution  of  colloidal  silver,  which  is  moro  opaque  to  the  rays  than  the 
tissues.  By  this  procedure  one  can  differentiate  between  normal  pelvis, 
hydronephrosis,  tumors  of  the  kidney,  and  abscess  of  the  kidney  if  it  drains 
into  the  pelvis.  The  shape  of  the  kidney  pelvis  as  shown  on  the  plate  is  char- 
acteristic in  each.  Dilatations  and  kinks  in  the  ureter  can  often  be  shown 
in  the  same  manner.  Such  examination  requires  the  assistance  of  an  expert 
in  ureteral  catheterization.  Renal,  ureteral,  and  vesical  calculi  are  readily 
demonstrable  except  those  composed  purely  of  uric  acid.  This  variety  is 
occasionally  found  in  the  bladder. 

Diseases  of  the  bones  and  joints  which  cause  absorption,  destruction, 
or  proliferation  of  lime  salts  or  cartilage  lend  themselves  most  aptly  to  ront- 
genographic study.  In  children  the  development  of  the  skeletal  structures 
is  readily  portrayed.  The  extent  of  the  disease  as  well  as  its  nature  is  usually 
shown,  hence  a  prognosis  as  well  as  diagnosis  may  be  more  accurately  made. 

The  value  of  the  Rontgen-ray  method  of  examination  in  excluding  sus- 
pected conditions  is  scarcely  less  than  in  determining  existing  conditions. 

The  knowledge  of  the  expert  is  as  necessary  to  the  explanation  of  skia- 
grams as  to  the  making  of  them  and  it  is  always  to  be  borne  in  mind  that 
X-ray  pictures  are  to  be  interpreted  as  shadows  and  not  as  lesions. 


PART   III. 

OF  SYMPTOMS  AND   SIGNS. 


I. 

GENERAL  CONSIDERATIONS. 

Symptoms  and  Signs. — The  clinical  phenomena  of  disease  are  divided 
into  two  general  groups:  (a)  subjective,  those  obtained  by  inquiry,  and 
(b)  objective,  those  learned  by  observation.  The  former  are  known  as 
symptoms,  the  latter  as  signs.  These  may  be  general,  as  fever,  debility, 
or  emaciation,  or  local,  as  pain,  dyspncea,  or  dulness  upon  percussion. 
The  dividing  line  between  symptoms  and  signs  is  not  well  defined.  Pain 
and  nausea  are  symptoms  of  which  nothing  can  be  learned  by  observa- 
tion alone;  an  endocardial  murmur  or  pleural  friction  rub,  signs  concern- 
ing which  the  patient  can  give  no  personal  account;  while  retelling,  cough, 
and  palpitation  partake  at  once  of  the  nature  of  both  signs  and  symptoms 
and  may  be  referred  to  the  one  or  other  group  of  clinical  phenomena  accord- 
ing to  the  point  of  view  from  which  they  are  regarded.  Symptomatology 
is  that  department  of  medical  science  which  has  for  its  object  the  consider- 
ation of  the  symptoms  of  disease;  semeiology  (ayfieiov,  a  sign),  that 
which  has  for  its  object  the  consideration  of  the  signs  of  disease.  Just  as 
symptoms  and  signs  are  not  always  to  be  closely  distinguished,  so  the 
scope  and  subject  matter  of  these  sub-sciences  of  medicine  largely  overlap, 
and  symptomatology  and  semeiology  are  frequently  used  interchangeably. 
Pure  symptoms  are  limited  in  number  as  compared  with  signs,  and,  since 
they  are  wholly  subjective  and  our  knowledge  of  them  is  based  upon  the 
statements  of  the  patient,  who  may,  according  to  his  temperament  or  for 
purposes  of  his  own,  either  unintentionally  or  wilfully  misrepresent  them, 
they  are  of  far  less  value  in  diagnosis  than  signs.  Symptoms,  which  have 
their  origin  in  the  deranged  sensations  of  the  patient,  stand  in  contrast  to 
signs,  which  are  dependent  upon  changes  in  organs  or  tissues.  For  this 
reason  qualifying  adjectives  are  sometimes  employed,  and  we  speak  of 
rational  symptoms  and  physical  signs.  It  is  customary,  however,  to 
apply  ihe  word  symptom  to  many  of  the  objective  phenomena  of  disease. 

Syndrome  is  a  term  used  to  designate  a  set  of  concomitant  symptoms, 
especially  the  concurrence  of  a  group  of  symptoms  not  indicating  a  disease 
with  well-determined  anatomical  lesions,  as  for  example  fever,  seasickness, 
and  astasia-abasia;    a  symptom-complex;    a  symptom-group. 

Diseases  upon  one  basis  of  classification  are  divided  into  constitutional 
or  general,  namely,  those  in  which  the  organism  as  a  whole  reacts  to  the 
pathogenic  influence;  and  local  or  organic,  in  which  the  lesions  involve 
primarily  or  chiefly  a  viscus  or  an  anatomical  tract.     General  symptoms 

405 


406  MEDICAL  DIAGNOSIS. 

are  often  the  expression  of  a  local  disease  and  local  symptoms  the  expression 
of  a  general  disease;  thus  emaciation,  pallor,  and  a  profound  cachexia 
attend  the  progress  of  carcinoma  of  the  stomach,  while  tenderness  in  the 
right  iliac  fossa,  diarrhoea,  and  tympany  are  symptoms  of  enteric  fever. 


II. 

APPEARANCE;    TEMPERAMENT  AND   DIATHESIS;    FACIES; 
FORM    AND    NUTRITION. 

APPEARANCE. 

The  general  appearance  of  the  patient  when  first  seen  forms  the  ground- 
work for  the  study  of  his  present  condition — the  status  prossens.  Whatever 
knowledge  may  be  subsequently  obtained  of  the  facts  in  the  case,  the 
general  appearance  constitutes  the  point  of  departure  for  the  direct  diag- 
nosis. In  the  successful  clinician  the  habit  of  observing  and  noting  its 
various  details  with  great  rapidity  is  cultivated  in  a  high  degree.  The 
facial  expression,  state  of  nutrition,  movements  and  attitude,  mode  of 
speech,  and  mental  condition  are  at  once  observed.  An  opinion  is  formed 
as  to  what  manner  of  man  the  patient  is.  Information  as  to  his  social 
position,  occupation,  and  habits  may  be  learned  from  his  dress:  Is  he  neat 
or  slovenly?  Are  his  clothes  buttoned  awry?  Is  his  collar  loose  to  make 
room  for  swollen  glands  or  a  goitre?  Do  his  trousers  show  the  white  stains 
of  diabetic  urine?  Has  he  the  tabetic  or  steppage  gait  or  the  festination 
of  paralysis  agitans?  Has  he  the  flushed  face  with  dilated  venules  and  the 
trembling  tongue  of  the  alcoholic,  or  the  enlarged  girth  and  the  waistband 
lengthened  with  a  loop  of  string,  of  hepatic  cirrhosis  with  ascites?  The 
hands  tell  a  story  of  their  own.  We  note  at  a  glance  that  they  are  white 
and  soft  and  the  finger-nails  are  clean,  as  occurs  mostly,  but  not  always, 
with  men  of  leisure  and  professional  men;  that  they  are  large  and  callous, 
as  in  those  who  follow  the  sea;  coarse,  sunburnt,  and  freckled,  as  in  the 
farmer;  or  that  they  bear  the  oil  and  grime  of  the  mechanic  who  has  hurried 
from  his  work.  The  trembling  hand  of  alcoholism,  the  pill-rolling  move- 
ments of  paralysis  agitans,  the  nodules  and  tophi  of  gout,  the  deformities 
and  relaxed  ligaments  of  arthritis  deformans,  and  the  spade-like  hands  of 
myxcedema  tell  their  own  tale. 

The  diagnosis  may  sometimes  be  made  at  a  glance.  The  flushed  face, 
hurried  breathing,  unilateral  movement  of  the  chest,  and  rusty  sputum  of 
pneumonia  scarcely  demand  the  additional  data  of  chill,  crepitant  rale, 
and  percussion  dulness;  nor  the  intense  headache,  opisthotonos,  vomiting, 
herpes,  and  petechia?  the  history  of  sudden  onset  or  the  epidemic  prevalence 
of  cerebrospinal  fever;  while  the  paroxysm  of  whooping-cough  is  in  itself 
diagnostic.  The  diagnosis  thus  made  cannot,  however,  be  called  intuitive. 
In  truth  there  is  no  such  thing  as  an  intuitive  diagnosis.  Before  a  conclu- 
sion is  reached,  however  brief  the  time,  the  clinician,  usually  without  being 
aware  of  his  mental  processes,  has  been  weighing  and  sifting  the  symptoms 


SYMPTOMS  AND  SIGNS:   TEMPERAMENT— DIATHESIS.    407 

and  assigning  to  each  its  proper  value  and  importance.  Such  a  diagnosis 
must  in  all  cases  be  personally  regarded  as  provisional  and  not  announced, 
however  tempting  the  circumstances,  until  sufficient  facts  for  its  full  sup- 
port have  been  obtained.  There  are  pitfalls  in  the  way  of  him  who  makes 
what  in  the  language  of  the  ward  classes  is  called  a  "snap  diagnosis." 
It  is  never  complete;  the  pneumonia  may  be  complicated  with  pericarditis. 
Such  a  diagnosis  is  sometimes  altogether  false;  there  are  cases  of  enteric 
fever  in  neurotic  individuals  in  early  life  that  closely  simulate  the  symp- 
tom-complex of  meningitis — the  so-called  cerebrospinal  form  of  enteric 
fever — and  a  child  long  convalescent  from  whooping-cough  may  under 
emotional  excitement  or  when  suffering  from  an  attack  of  subacute 
laryngitis  have  paroxysms  of  cough  with  whooping. 

TEMPERAMENT  AND   DIATHESIS. 

Under  the  teaching  of  the  French  school  great  importance  was  at  one 
time  attached  to  temperament  or  diathesis  as  a  condition  of  the  hereditary 
constitution  manifested  in  the  general  appearance  of  the  patient.  Less 
attention  is  paid  to  this  subject  now  than  formerly,  but  no  very  close 
observation  is  required  to  establish  the  fact  that  many  individuals  have  in 
common  peculiarities  of  physical  and  mental  organization  very  different 
from  those  of  others  and  that  corresponding  differences  in  general  health 
and  tendency  to  disease  occur.  Disregarding  misleading  refinements  and 
combinations  the  following  principal  forms  may  be  described: 

The  sanguine,  sometimes  called  the  Arthritic  or  Gouty  Tempera- 
ment.— The  characteristics  of  this  condition  are  well-developed  bones  and 
muscles,  a  fine  skin,  good  hair,  fair  complexion,  good  nutrition,  a  general 
appearance  of  health  and  energy.  The  physiological  processes  are  active, 
the  digestion  excellent,  the  bowels  regular,  the  respiratory  excursus  large, 
the  action  of  the  heart  regular,  the  pulse  full  and  strong.  In  disposition 
persons  of  this  temperament  are  cheerful  and  hopeful,  hence  the  adjective 
"sanguine"  often  applied  to  them.  Mentally  they  are  active  but  of  delib- 
erate judgment  and  they  do  a  large  part  of  the  world's  work.  They  are 
especially  liable  to  bronchitis  and  other  catarrhal  affections  and  to  arterio- 
sclerosis, and  in  advancing  life  prone  to  sclerotic  changes  in  the  valves  ot 
the  heart,  aneurism,  angina  pectoris,  or  apoplexy. 

The  nervous  diathesis  shows  itself  commonly  in  slender  or  under- 
sized individuals  who  are  often  poor  and  irregular  eaters,  not  well  nourished. 
Such  persons  are  alert  and  active  but  often  incapable  of  sustained  effort. 
The  physiological  processes  are  not  always  well  performed.  They  often 
possess  high  intellectual  ability  and  are  subject  to  intense  emotions.  They 
are  predisposed  to  derangements  of  the  digestive  apparatus  and  to  head- 
ache from  slight  causes.  They  take  things  to  heart,  as  the  phrase  goes, 
and  are  liable  to  break  down  under  stress  of  work  and  worry.  Neuras- 
thenia, hysteria,  migraine,  and  other  functional  diseases  of  the  nervous 
system  and  insanity  are  common. 

The  Bilious  Diathesis. — The  complexion  is  dark,  the  hair  dark 
brown  or  black,  often  coarse  and  oily,  the  skin  shows  a  tendency  to  local 
pigmentation  which  varies  in  intensity,  especially  about  the  eyes  and  brow. 


408  MEDICAL  DIAGNOSIS. 

The  appetite  is  irregular,  often  poor,  fats  and  sugars  are  digested  with 
difficulty,  and  the  bowels  are  sluggish.  The  nutrition  is  not  good,  though 
women  of  this  temperament  often  grow  stout  in  middle  life.  They  are 
subject  to  attacks  of  that  form  of  gastrohepatic  catarrh  popularly 
described  as  biliousness  and  are  often  at  such  times  faintly  jaundiced- 
Nausea  and  headache  are  common.     Such  persons  often  lack  energy. 

The  Lymphatic  Diathesis. — The  muscles  are  soft  and  flabby,  there 
is  very  often  a  slight  excess  of  subcutaneous  fat.  The  skin  is  pallid,  the 
physiological  processes  are  sluggishly  performed.  Mentally  such  persons  are 
dull  and  unresponsive.  They  are  subject  to  enlargements  of  the  subcuta- 
neous lymph-nodes  and  are  liable  to  chlorosis  and  other  forms  of  anaemia. 

The  Strumous  Diathesis. — The  word  struma,  meaning  scrofula  or 
glandular  tuberculosis,  though  still  applied  in  another  sense  to  goitrous 
swellings,  has  lost  its  significance  in  medicine  and  has  almost  disappeared 
from  the  modern  literature.  The  term  strumous  diathesis  has,  however, 
a  very  definite  significance  and  is  applied  to  a  bodily  constitution  unfor- 
tunately too  common.  The  bony  framework  departs  widely  from  the 
normal  type.  The  chest  is  small  and  flat,  the  shafts  of  the  long  bones 
slender,  their  epiphyses  enlarged  and  thickened.  The  musculature  is 
undeveloped  and  soft.  The  appearance  is  characteristic,  the  head  is  large, 
the  cranial  bosses  prominent,  the  forehead  broad  and  protuberant,  the 
lips  full,  the  nose  short  and  broad,  its  alas  thickened,  the  lower  jaw  small, 
the  teeth  carious,  the  complexion  commonly  fair,  the  hair  fine  and  the  eye- 
lashes long.  The  nutrition  is  poor  and  the  general  appearance  of  such 
individuals  delicate  and  frail.  The  cervical  lymphatics  are  often  enlarged. 
Such  persons  are  subject  to  tuberculosis  of  the  glands,  bones,  and  lungs 
and  miliary  tuberculosis,  and  usually  die  at  an  early  age.  They  are  fre- 
quently the  offspring  of  tuberculous  parents.  Whether  the  constitutional 
peculiarities  which  go  to  make  up  the  so-called  strumous  diathesis  are  to 
be  ascribed  to  profound  derangements  of  nutrition,  transmitted  from 
tuberculous  parents,  or  to  a  latent  tuberculosis  acquired  in  the  earliest 
period  of  life  cannot  always  be  determined. 

Cachexia  is  a  term  used  to  describe  the  ravages  of  certain  chronic 
wasting  diseases,  especially  untreated  malaria,  the  graver  forms  of  syphilis, 
and  carcinoma,  particularly  when  it  involves  the  digestive  organs.  The 
cachexias  present  a  combination  of  profound  anaemia,  extreme  emaciation 
and  debility,  and  a  diffuse,  faint,  muddy  pigmentation  of  the  skin. 

Dyscrasia  is  a  depraved  state  of  the  system,  especially  of  the  blood, 
due  to  constitutional  disease.  In  the  words  of  Bristowe  it  is  a  general 
deterioration  of  health  and  functional  disturbance  caused  by  the  deflec- 
tion of  nutrition.  We  speak  of  a  tuberculous,  malarial,  syphilitic,  or 
cancerous  dyscrasia. 

FACIES. 

The  appearance  of  the  face  is  often  of  diagnostic  importance.  It 
frequently  indicates  the  subjective  sensations  and  not  rarely  the  psychical 
condition.  To  say  that  a  patient's  expression  is  that  of  suffering,  acute 
pain,  anxiety,  overwhelming  illness,  or  that  it  is  excited,  dull  or,  stupid,  is 
intelligible  without  further  comment.     The  face  is  an  index  of  the  physio- 


SYMPTOMS  AND  SIGNS:   FACIES.  409 

logical  age  of  the  patient.  The  gray  hair,  wrinkled  brow,  arcus  senilis,  and 
hanging  folds  of  skin  about  the  neck  are  very  suggestive.  They  enable  the 
clinician  to  compare  the  apparent  age  of  the  patient  with  his  actual  age  as 
measured  by  years.  The  facies  of  fever  patients  is  often  characteristic. 
In  the  stage  of  excitement  there  is  an  intensification,  in  that  of  depression 
a  blurring  of  expression,  accompanied  by  a  peculiar  moist  appearance  of 
the  eye,  a  feverish  flush  and  often  a  very  slight  turgescence  of  the  skin 
of  which  I  shall  speak  more  fully  in  a  later  paragraph.  Equally  character- 
istic is  the  facies  of  dyspncea.  Here  also  puffing  or  turgescence  is  present, 
sometimes  marked,  and  there  is  cyanosis,  and  with  these  symptoms  dilated 
nostrils,  an  open  mouth,  and  hurried  breathing.  The  flushed  face  and 
bright  eyes  that  follow  too  much  wine,  and  the  bloated  countenance  with 
its  blurred  lines,  dilated  venules,  thickened  nose,  acne,  and  trembling  tongue 
of  some  forms  of  chronic  alcoholism  are  sadly  familiar.  The  characteristic 
change  of  the  countenance  seen  in  those  about  to  die,  especially  in  patients 
suffering  from  ileus,  peritonitis, 
cholera,  and  similar  diseases,  is 
described  as  the  facies  Hip- 
pocratica.  The  changes  are 
largely  due  to  a  diminution  in 
the  contents  of  the  blood-  and 
lymph-vessels  and  muscular  re- 
laxation. The  skin  falls  back 
upon  the  bones,  the  lines  of 
expression  are  more  sharply  de- 
fined than  normally,  the  nose 
is  sharp  and  pinched,  the  eyes 

SUnken,     the      temples       hollow.  Fig.  1 62.— Cerebrospinal  fever,  fourth  day  of  attack. 

Tin^l.  il...  ~  ,11 +1 ;„  „~„,„  J_  Fever  facies;  patch  of  herpes;  retraction  of  head. — Munic- 

\V  it  h  the  pallor  there  is  some  de-     ipai  Hospital,  Royer. 

gree  of  cyanosis  which  gives  the 

skin  a  leaden  or  faintly  livid  hue.   The  surface  is  cool  and  bathed  with  sweat. 

The  appearance  of  the  face  in  the  following  conditions  is  suggestive 
if  not  always  characteristic: 

Enteric  Fever.— In  well-developed  cases  the  face  is  dull,  expression- 
less, pallid,  with  a  faint,  dusky  flush  over  the  cheek  bones,  often  slightly 
drawn.  The  eyelids  are  half  closed,  the  lips  pallid  and  separated,  in  neg- 
lected cases  sordes  may  be  seen  upon  the  teeth.  Such  also  is  the  facies  of 
patients  profoundly  septic.  It  occurs  in  the  so-called  "typhoid  state" 
and  is  seen  in  puerperal  septicaemia,  malignant  endocarditis,  infection  after 
surgical  operations,  and  the  like. 

Acute  Peritonitis. — The  expression  is  one  of  intense  suffering, 
the  face  is  pale  and  drawn,  sometimes  the  upper  lip  is  contracted  so  as  to 
show  t  he  teeth. 

Pneumonia.  -A  circumscribed  flush  of  one  or  both  cheeks  may  be 
seen;  it  may  be  bright  or  dusky.  When  one  cheek  only  is  flushed  it  is  usu- 
ally that  upon  the  side  of  the  pulmonary  lesion.  With  this  appearance  in 
grave  cases  are  associated  the  facial  changes  peculiar  to  dyspncea.  A 
similar  appearance  accompanies  the  symptomatic  fever  of  phthisis  hectic 
fever.    The  flushing  is,  however,  brighter  and  not  so  distinctly  circumscribed. 


410 


MEDICAL  DIAGNOSIS. 


It  is  in  strong  contrast  with  the  pallor  of  the  brow  and  neck.     The  strik- 
ing appearance  of  such  patients  is  intensified  by  expanding  nostrils,  hurried 

-     breathing,  bright  moist  eyes,  and  an 
intense,  often  eager,  expression. 

Tetanus. — The  facial  peculiarity 
is  startling.  Under  the  action  of  the 
toxin  of  the  disease  all  the  muscles 
of  expression  are  thrown  into  tonic 
spasm  more  or  less  intense  at  the 
same  time,  whereas  under  ordinary 
circumstances  the  varying  moods 
are  expressed  by  the  contraction 
|Jf  now  of  one  set  of  muscles,  now  of 

another.  The  lips  are  parted  and 
the  corners  of  the  mouth  drawn  up 
as  in  laughter  or  grinning,  while  other 
parts  of  the  face  and  especially  the 
brow  are  contracted  and  thrown 
into  folds  as  though  in  grief  or 
anger  —  risus  sardonicus  of  the 
older   writers. 

The  Exanthemata — The  appear- 
ance of  the  face  in  the  eruptive  infec- 
tious diseases  is  usually  diagnostic. 
The  diffuse  uniform  rash,  often  in 
strong  contrast  with  the  white  border 
around  the  mouth,  and  the  slightly  tumid  skin  of  scarlet  fever,  the  turgid 
skin,  coarse  measly  rash  with  its  crescentiform  arrangement  and  coryza  in 
measles,  the  pock  in  different  stages 
of  development  with  its  umbilicated 
vesicles  or  hideous  pustules  and 
crusts  and  swollen  and  disfigured  fea- 
tures in  the  variolous  diseases,  and 
the  pellucid  hemispherical  vesicles 
or  crusts  without  areola^  scattered 
singly  or  in  groups  about  the  brow  or 
mouth  in  varicella,  are  characteristic. 
Mumps. — The  deformity,  alike 
when  it  involves  one  or  both  sides, 
is  characteristic.  The  swelling  is  at 
first  limited  to  the  region  of  the 
parotid  gland,  behind  the  jaw  and 
below  the  ear,  but  the  surrounding 
oedema  sometimes  assumes  remark- 
able proportions.  The  lobule  of 
the  ear  stands  out  at  right  angles 
to  the  side  of  the  head.  When 
the  swelling  advances  upon  the  cheeks,  the  corners  of  the  mouth  are 
slightly  drawn  up.     The  parotid  bubo  which  occurs  in  some  cases  of  enteric 


Fig.  163.- 


-Parotid  bubo  complicating  enteric  fever. 
— Jefferson  Hospital. 


Fie 


104.— a: 


ema   in   acute   nephritis. — Jefferson 
Hospital. 


SYMPTOMS  AND  SIGNS:   FACIES. 


411 


Fk 


165. — Facies  in  a  case  of  adenoid  vegetations 
of  the  nasopharynx. — Merrick. 


fever,  pneumonia,  septicaemia,  and  other  grave  infections  superadds 
to  the  facies  of  those  conditions  a  deformity  somewhat  like  that  of 
mumps.     The  overlying  skin  is  usually  of  a  dusky  red  color. 

Renal  Disease. — The  striking 
appearance  of  the  patient  in  some 
forms  of  acute  nephritis  and  very 
commonly  in  chronic  parenchyma- 
tous nephritis  is  of  diagnostic  impor- 
tance. It  is  characterized  by  intense 
waxy  pallor,  marked  cedema  of  the 
eyelids,  and  general  puffiness  of  the 
face  by  which  the  lines  of  expression 
are  to  some  extent  impaired. 

Hepatic  Disease.  —  In  chronic 
diseases  of  the  liver  and  especially 
in  cirrhosis  and  gall-stone  disease  the 
facies  is  peculiar.  The  features  are 
as  a  rule  sharp,  the  face  thin,  con- 
junctivae muddy,  venules  dilated, 
lips  red,  and  skin  slightly  jaundiced 
or  subicteroid — facies  hepatica  of 
the  older  writers. 

Malaria. — The  pallor,  sallow- 
ness,  and  muddy  conjunctivae  which 

are  so  commonly  seen  in  intensely  malarious   districts   are  not  without 

considerable    value    in    the    diagnosis    of    the    cachexia    of    this    disease. 

Syphilis. — The  face  may  show  characteristic  eruptions   at   different 

stages  of  the  disease.    The  coppery  flat  papule  or  papulosquamous  syphilide 

upon  the  temples  and  forehead — 
coroxa  veneris — is  common.  The 
face  of  the  patient  under  treatment 
may  show  not  the  eruption  of  the 
disease  but  the  drug  exanthem 
produced  by  the  iodides.  Babies 
suffering  from  inherited  syphilis  are 
usually  pale,  weazened,  and  wrin- 
kled. They  look  curiously  like 
miniature  old  men.  They  have 
snuffles  and  superficial  excoriations 
about  the  angles  of  the  nose  and 
corners  of  the   mouth. 

Rickets. — The  frontal  and  pari- 
etal eminences  are  exaggerated 
and  the  top  of  the  skull  flattened, 
so  that  the  head  assumes  an  appear- 
ance of  squareness  and  is  some- 
times spoken  of  as  box-shaped. 
Hydrocephalus. — The  head  is  characterized  by  its  spherical  shape, 
great  size,  and  protruding  eyeballs,  the  result  of  depression  of  the  orbital 


i'MI. 


166. — Exopht  halmic  goil  re. 
Hospital. 


-Jefferson 


412 


MEDICAL  DIAGNOSIS. 


Fig.  167. — Leprosy. 


plate  of  the  frontal  bone.  The  exophthalmus  is  sometimes  so  marked 
that  the  eyelids  cannot  be  closed.    The  size  of  the  head  is  often  enormous, 

its  diameter  may  reach  20  to  25  cm. 
in  a  child  a  few  years  old.  The  face 
on  the  contrary  appears  very  small, 
its  expression  vacant  and  fatuous. 
The  cranial  bones  are  separated 
and  exceedingly  thin.  The  hair  is 
scanty  and  the  veins  may  be  seen 
beneath  the  skin. 

Hypertrophy  of  the  Tonsils 
and  of  the  Adenoid  Tissue  of  the 
Pharnyx. — As  a  result  of  habitual 
mouth-breathing  the  expression  of 
the  countenance  gradually  under- 
goes characteristic  changes,  the  face 
becomes  apathetic  and  vacant,  the 
nostrils  are  narrow,  the  lips  thick, 
and  there  is  projection  of  the  upper 
jaw  and  lip. 

Myxoedema.  —  The  face  is 
"moon-shaped,"  swollen  and  flattened,  the  nose  broad,  the  mouth 
coarse  and  large,  the  lines  of  expression  obliterated.  The  skin  is  yellow, 
waxy,  dry,  and  scaly,  the  hair  thin  and  scanty,  the  cheeks  and  nose  flushed. 

Cretinism. — The  face  is  large, 
the  lips  thick,  the  tongue  large  and 
protruded,  the  mouth  open  and  drool- 
ing, the  nose  flattened,  the  skin  pallid 
and  waxy,  the  expression  idiotic. 

Acromegaly. — The  bony  hyper- 
trophy is  especially  manifested  in 
the  supra-orbital  arches,  the  malar 
bones,  and  in  the  projecting  lower 
jaw.  The  forehead  is  receding,  the 
nose  is  increased  in  size,  }ts  alae  dis- 
tended, the  eyelids  enlarged  and 
thickened.  The  cartilages  of  the  ear 
are  also  enlarged  so  that  very  often 
the  ears  stand  out  conspicuously 
from   the    head. 

Exophthalmic  Goitre.  —  The 
protrusion  of  the  eyeballs,  some- 
times so  marked  that  the  patient 
can  no  longer  close  his  eyes,  pro- 
duces a  remarkable  change  in  the 
expression.      In    its    lighter    grades 

the  air  is  that  of  surprise,  but  when  the  exophthalmus  is  marked  the 
patient  has  a  frightened  or  astonished  look  which  is  intensified  by  the 
characteristic   tremor.     The  enlargement    of   the    thyroid    body   as   well 


Fig.  168. — Facial  paralysis  following  cerebrospinal 
fever. — Jefferson  Hospital. 


SYMPTOMS  AND  SIGNS:   FACIES. 


413 


Hemiatrophia  facialis. — After  Ilirt. 


as  the    visible    pulsation    and    venous    distention    add    to    the    peculiar 

expression  of   the  countenance  in  this  disease. 

Leprosy.— The  development  of   leprous    nodules  upon   the  face  and 

the  thickening  of  the  skin  give  rise  to  remarkable  deformities.     The  chin, 

lips,  nose,  eyelids,  and  ears  undergo 

peculiar   and   characteristic    changes, 

in    consequence    of    which    the    face 

assumes  the  appearance  of  a  hideous 

expressionless   mask.      Baldness,   loss 

of   the   eyebrows,   lashes,  and   beard, 

and  ulceration  also  occur.     The  dis- 
figurement suggests  the  conventional 

face  of  the  satyr  or  the  lion  and  is 

often   spoken   of   as   leonine — pacies 

LEONINA. 

Nervous  and  Mental  Disease. — 

In  functional  nervous  diseases  there 

are  frequently  changes  in  the  coun- 
tenance more  easily  recognized  than 

described.    The  pallid,  slightly  drawn 

face  of  the  neurasthenic  with  its  habitual    air  of   depression   is   familiar 

to  the   practitioner.     These  traits,  somewhat  intensified,   are  common  in 

women  broken  down  by  frequent  child-bearing  and  in  those  who  suffer 

from  disease  of  the  pelvic  organs — facies  tjterixa.     In  hysteria  the  face 

usually  remains  free  from  the  motor 
disturbances  so  common  elsewhere,  par- 
ticularly in  the  lower  extremities.  There 
is  neither  spasm,  paralysis,  nor  other  con- 
stant characteristic  save  that  it  reflects, 
often  intensely,  the  varying  uncontrolled 
emotions  of  the  patient.  Equally  without 
cause  laughter  succeeds  tears  or  vivacity 
is  followed  by  an  air  of  sullen  and  dogged 
indifference.  Central  or  peripheral  dis- 
ease of  the  nervous  system  may  manifest 
itself  in  spasmodic  twitching  of  the  facial 
muscles.  Mimetic  spasm  or  convulsive 
tic  consists  of  clonic  contractions  of  the 
muscles  supplied  by  tlie  facial  nerve. 
They  are  usually  limited  to  the  region 
about  the  eye  or  above  the  corner  of  the 
mouth.  Sometimes  they  involve  the 
greater  pari  of  one  or  both  sides  of  the 
face.  Similar  contractions  of  the  mus- 
cles of  expression  occur  in  children  and 
are  known  as  habit  spasm.  In  peripheral  facial  palsy  the  affected  side  is 
smooth  ami  motionless,  the  wrinkles  of  the  forehead  and  the  labionasal 
fold  disappear,  the  comer  of  the  mouth  is  lowered  and  frequently  drools, 
and  the  mouth  itself  is  slightly  drawn  toward  the  sound  side.    The  eyelids 


Fir;.  170.    Paranoia, homicidal  type.    Chase. 


414  MEDICAL  DIAGNOSIS. 

are  motionless  and  can  only  be  partly  closed.  The  tears  fall  over  the 
cheeks.  The  contrast  with  the  opposite  side  is  intensified  upon  efforts  to 
smile  or  close  the  eye.  When  the  paralysis  is  due  to  central  causes  the 
lower  segment  of  the  face  is  chiefly  involved.  In  old  cases,  after  contract- 
ure has  taken  place  the  mouth  is  drawn  toward  the  affected  side. 

In  organic  disease  tremor  and  paralysis  are  significant.  Tremor  of 
the  lips  and  tongue  occurs  in  chronic  alcoholism.  Fibrillary  tremor  is  fre- 
quently associated  with  progressive  palsy.  In  bulbar  paralysis  the  lips 
are  thin,  compressed,  and  tremulous,  the  tongue  is  wasted  and  protruded 
with  difficulty,  and  there  is  dribbling  of  saliva.  In  paralysis  agitans  the 
appearance  of  the  countenance  is  very  strikingly  changed.  The  face  has 
a  curious  stiff,  expressionless  immobility  which  has  given  rise  to  the  name 
Parkinson's  mask.  There  is  often  druling  from  the  partially  closed  mouth 
and  the  lips  and  tongue  frequently  share  in  the  general  tremor.  In  general 
paresis  local  twitchings  of  the  face,'  irregularity  of  the  pupils,  and  slight 
tremulousness  of  the  lips  are  suggestive.  The  rare  disease  facial  hemi- 
atrophy is  a  trophic  neurosis  affecting  one  side  of  the  face,  commonly  the 
left.  The  soft  tissues  and  bones  are  alike  involved  in  the  atrophic  process, 
which  is  sharply  limited  at  the  mesial  line.  The  eye  is  sunken  and  the 
corresponding  half  of  the  tongue  and  soft  palate  may  be  implicated. 

The  facies  in  disease  of  the  mind  is  often  characteristic.  The  depres- 
sion of  melancholia,  the  agitation  and  eagerness  of  acute  mania,  the  alert 
slyness  of  chronic  mania,  the  irregular  contractions  of  the  facial  muscles  in 
paresis,  the  fixed  expression  in  paranoia  with  homicidal  tendencies,  the 
fatuous  face  of  the  imbecile,  are  well  known  to  every  student  of  psychiatry. 

FORM  AND  NUTRITION  OF  THE  BODY. 

These  are  important  factors  in  the  problem  of  diagnosis.  The  normal 
of  different  individuals  varies  within  wide  limits.  It  is  scarcely  necessary 
to  say  that  persons  may  be  tall  or  short,  stout  or  slight,  fat  or  lean,  without 
manifesting,  even  in  wide  ranges  of  difference  in  these  respects,  either  the 
predisposition  to  or  the  symptoms  of  disease.  Health  consists  in  the  ability 
of  the  individual  organism  to  maintain  its  normal  activities  in  the  environ- 
ment in  which  it  happens  to  be  placed.  The  somewhat  pallid,  hollow- 
chested  and  slender  book-keeper  often  has  good  health  and  length  of  days 
while  the  clear-eyed,  bright-skinned,  deep-chested,  well-developed  athlete 
not  infrequently  breaks  down  in  early  middle  life.  Variations  in  these 
respects  give  rise  to  predisposition  or  constitute  the  indications  of  disease 
when  they  become  excessive.  We  say  that  a  man  has  a  splendid  or  powerful 
physical  development  when  the  measurements  of  his  body  transcend  the 
average,  but  the  health  of  another  who  does  not  reach  the  average  may 
be  equally  good.  Not  only  anatomical  structure  but  also  physiological 
function  are  to  be  considered.  Subtle  hereditary  tendencies,  the  value  of 
which  we  cannot  always  estimate,  and  the  shifting  balance  between  the 
powers  of  the  organism  and  the  work  which  it  is  called  upon  to  do  engage 
our  attention.  To  say  that  the  physical  organization  is  feeble,  delicate, 
slender,  robust,  or  muscular  needs  no  further  explanation.  The  condition 
of  nutrition  shows  itself  furthermore  in  the  development  and  tonicity  of 


SYMPTOMS  AND  SIGNS:   FORM  AND  NUTRITION.         415 

the  muscles  and  especially  in  their  relation  to  the  amount  of  subcutaneous 
fat — panniculus  adiposus.  On  the  one  hand  a  moderate  amount  of  sub- 
cutaneous fat  is  not  incompatible  with  excellent  health,  an  excess  is  alike 
inconvenient  and  dangerous,  and  obesity  constitutes  a  positive  disease. 
On  the  other  hand  a  spare  man  may  be  equally  healthy,  while  rapid  loss 
of  fat  is  a  suspicious  symptom  and  emaciation  an  alarming  sign  of  disease. 
In  estimating  the  value  of  these  conditions  the  hereditary  tendencies,  the 
occupation,  the  age,  and  the  sex  of  the  patient  must  receive  due  consideration. 
In  young  infants  the  panniculus  is  well  developed.  In  infancy  it  often 
dwindles,  only  to  increase  again  as  puberty  approaches.  At  this  period  it 
not  infrequently  again  becomes  excessive.  In  advanced  life  the  fat  com- 
monly diminishes  and  the  aged  as  a  rule  are  spare.  The  panniculus  is  usually 
greater  in  women  than  in  men  and  very  often  increases  after  the  menopause. 
In  most  chronic  diseases  the  nutrition  is  impaired  because  either  sufficient 
nourishment  is  not  taken  on  account  of  loss  of  appetite,  or  that  which  is 
taken  is  not  assimilated.  A  high  degree  of  emaciation  attends  diseases  of 
the  digestive  organs  and  chronic  febrile  diseases,  for  example,  carcinoma, 
especially  carcinoma  of  the  oesophagus  or  pylorus,  enterocolitis  with  exces- 
sive diarrhcea,  some  forms  of  diabetes  mellitus,  phthisis,  and  enteric  fever 
with  repeated  relapses.    Wasting  of  fat  is  accompanied  by  wasting  of  muscle. 

Weight. — The  weight  of  the  body  and  the  amount  of  subcutaneous 
fat  may  be  approximately  estimated  by  inspection,  but  this  method  is 
uncertain  and  practically  valueless  in  determining  the  progress  of  gain  or 
loss.  Accurate  data  can  only  be  obtained  by  the  use  of  scales  at  regular 
intervals  and  the  preservation  of  the  records  for  comparison.  Small  plat- 
form scales  provided  with  a  device  for  ascertaining  the  height  of  the  patient 
are  indispensable  in  the  consulting  room  of  the  medical  clinician  engaged 
in  the  treatment  of  chronic  cases.  The  automatic  weighing  machines  found 
in  public  places  in  the  cities  are  unreliable.  Allowance  must  be  made  for 
the  clothing  and  its  variations  in  the  different  seasons,  and  when  practica- 
ble the  wreight  should  be  obtained  shortly  after  the  voidance  of  urine  and 
an  action  of  the  bowels",  and  before  a  meal.  Errors  of  two  or  three  pounds 
may  thus  be  eliminated,  though  for  practical  purposes  in  the  long  run  slight 
fluctuations  in  the  weight  may  be  disregarded  in  the  course  of  chronic 
disease.  Many  healthy  individuals  show  an  annual  oscillation  of  several 
pounds  in  net  weight,  allowance  being  made  for  clothing,  the  minimum 
being  reached  in  the  spring  or  early  summer,  the  maximum  in  the  autumn 
or  beginning  of  the  winter.  The  body  weight  should  be  taken  according  to 
the  requirements  of  individual  cases  at  regular  intervals  of  a  week  or 
longer.     Daily  observations  are  unnecessary. 

The  relation  of  the  average  body  weight  to  the  age  and  height  of 
healthy  individuals  is  set  forth  in  the  following  tables: 

Average  Weight  of  Healthy  Adult  Males. — Hutchinson. 

4  ft.  6  in.  to  5  ft.     0  in 92.26  lbs. 

5  ft.  0  in.  to  5  ft.     1  in 115.52  lbs. 

.")  ft,  2  in.  to  o  ft.     3  in 127.86  lbs. 

5  ft.  4  in.  to  5  ft.     5  in 139.17  lbs. 

5  ft.  6  in.  to  5  ft.     7  in II  L29  lbs. 

5  ft.  8  in.  to  5  ft.     9  in 157.76  lbs. 

5  ft.  10  in.  to  5  ft.   11    in 170.86  lbs. 

5  ft.  11  in.  to  6  ft.     0  in 177.25  lbs. 


416  MEDICAL  DIAGNOSIS. 

Infants,  whether  nursed  or  artificially  fed,  should  be  weighed  at  regular 
intervals  of  some  days  or  a  week.  Important  information  is  thus  obtained 
not  only  as  to  the  appropriateness  of  the  food  in  kind  and  quantity  but 
also  as  to  the  presence  of  assimilative  disorders.  The  average  normal 
weight  of  the  newborn  is,  according  to  Uffelmann,  in  girls  3000  grammes, 
in  boys  3500.  During  the  first  three  or  four  days  of  life  there  is  a  decrease 
of  from  220  to  300  grammes.  After  this  there  is  in  healthy  children  a 
progressive  increase. 

Average  Daily  Increase  in  Weight  During  the  First  Year  of  Life. — Gerhardt. 

1st    month 25  grammes. 

2nd  month 23  grammes. 

3rd  month 22  grammes. 

4th  month 20  grammes. 

5th  month 18  grammes. 

6th  month 17  grammes. 

7th  month 15  grammes. 

8th  month 13  grammes. 

9th  month 12  grammes. 

10th  month 10  grammes. 

11th  month 8  grammes. 

12th  month 6  grammes. 

The  weight  index  is  the  ratio  of  the  weight  of  a  given  infant  to  the 
weight  of  the  average  normal  infant  of  the  same  age. 

Useful  figures  to  remember  are  that  the  initial  weight  is  doubled  at 
5  months  and  trebled  at  15  months;  also  that  the  weight  at  one  year  is 
doubled  at  7  years  and  that  this  weight  is  again  doubled  at  14  years  (Rotch). 

In  infants  and  young  children  misleading  inferences  may  be  drawn 
from  a  consideration  of  the  weight  alone.  There  are  some  who  are  fat  and 
flabby  and  not  healthy.  Such  children  are  pallid,  they  lose  and  gain  weight 
rapidly  and  have  but  little  resisting  power  to  disease.  Then  there  are  many 
who  are  bright  and  rosy,  whose  flesh  is  firm  and  solid,  whose  nutrition  is 
good,  who  gain  in  weight  normally  and  are  not  liable  to  the  wasting  diseases. 

In  the  following  table  the  comparative  average  weight  of  the  sexes 
is  shown.  It  will  be  observed  that  from  •birth  until  the  sixth  year  the 
average  weight  in  the  two  sexes  is  nearly  the  same.  From  this  period  for 
some  years  the  weight  of  the  female  is  considerably  less  than  that  of  the 
male.  About  the  age  of  pu'berty  the  difference  becomes  less  marked,  though 
the  weight  of  the  female  is  decidedly  below  that  of  the  male. 

Average  Normal  Weight  in  the  Two  Sexes  at  Different  Periods  of  Life — Quetelet. 

Males.  Females. 

New-born 3.1  kgs.  6.82  lbs.  3.0  kgs.  6.60  lbs. 

1st    year 9.6  kgs.  19.S0  lbs.  8.6  kgs.  18.92  lbs. 

2nd  year 11.0  kgs.  24.20  lbs.  11.0  kgs.  24.20  lbs. 

3rd  year 12.5  kgs.  27.50  lbs.  12.4  kgs.  27.2S  lbs. 

4th  year 14.0  kgs.  30.80  lbs.  13.9  kgs.  30.58  lbs. 

5th  year 15.4  kgs.  33.88  lbs.  15.3  kgs.  33.66  lbs. 

6th  year 17.8  kgs.  39.16  lbs.  16.7  kgs.  36.74  lbs. 

7th  vear 19.7  kgs.  43.34  lbs.  17.8  kgs.  39.16  lbs. 

8th  year 21.6  kgs.  47.52  lbs.  19.0  kgs.  41.80  lbs. 

9th  year 23.5  kgs.  51.70  lbs.  21.0  kgs.  46.20  lbs. 

10th  vear 25.2  kgs.  55.44  lbs.  23.1  kgs.  50.82  lbs. 

11th  vear 27.0  kgs.  59.40  lbs.  25.5  kgs.  56.10  lbs. 

13th  year 33.1  kgs.  72.S2  lbs.  32.5  kgs.  71.50  lbs. 


SYMPTOMS  AND  SIGNS:    FORM  AND  NUTRITION.         417 

Males.  Females. 

15th  year 41.2  kgs.  90.64  lbs.  40.0  kgs.  88.00  lbs. 

17th  vear 49.7  kgs.  109.34  lbs.  46.8  kgs.  102.96  lbs. 

19th  year 57.6  kgs.  126.72  lbs.  52.1  kgs.  114.62  lbs. 

20th  vear 59.5  kgs.  130.90  lbs.  53.2  kgs.  117.04  lbs. 

25th  vear 66.2  kgs.  145.64  lbs.  54.S  kgs.  120.56  lbs. 

30th  vear 66.1  kgs.  145.42  lbs.  55.3  kgs.  121.66  lbs. 

60th  vear 61.9  kgs.  136.18  lbs.  54.3  kgs.  119.46  lbs. 

70th  year 59.5  kgs.  130.90  lbs.  51.5  kgs.  113.30  lbs. 

In  cases  of  tardy  or  interrupted  convalescence  from  an  acute  disease 
systematic  observations  of  the  weight  of  the  patient  at  intervals  of  a  week 
are  of  great  use.  A  sudden  arrest  or  decrease  in  weight  may  mark  the 
development  of  a  tuberculous  process.  Loss  of  weight  is  of  great  impor- 
tance in  the  diagnosis  of  early  phthisis.  An  arrest  of  the  loss,  still  more 
a  gain  in  body  weight,  must  in  most  cases  of  this  disease  be  regarded  as 
favorable.  There  are,  however,  exceptional  cases  in  which  after  a  consider- 
able steady  gain  in  weight  the  tuberculous  process  suddenly  makes  grave 
or  even  fatal  progress. 

The  weight  is  not  in  all  cases  merely  an  indication  of  the  general 
nutrition  and  amount  of  fat.  It  is  sometimes  made  up  in  considerable  part 
of  dropsical  effusions,  as  in  advanced  disease  of  the  mitral  valve  with  rup- 
ture of  compensation,  of  accumulations  in  the  serous  sacs,  as  in  massive 
serofibrinous  pleurisy  or  the  ascites  of  cirrhosis  of  the  liver,  of  the  contents 
of  cysts,  as  in  enormous  monolocular  disease  of  the  ovary,  or  of  new  growths 
of  large  size,  as  in  the  splenic  tumor  in  leukaemia  or  sarcoma  of  the  kidney 
in  young  children.  In  a  dropsical  patient  the  successful  use  of  salines  or 
diuretics  may  be  followed  coincidently  with  the  subsidence  of  the  ana- 
sarca by  a  reduction  in  weight  amounting  to  many  pounds  in  a  few  days. 
The  tendency  to  accumulate  excessive  fat  at  middle  life,  especially  in  women 
after  the  menopause,  must  be  regarded  as  pathological,  and  obesity,  as 
has  been  said,  constitutes  a  positive  disease.  The  gain  in  weight  occurs 
at  the  time  of  beginning  decrease  of  muscular  power,  at  the  period  of  physio- 
logical involution.  The  individual  must  carry  about  a  growing  mass  of 
inert  fat  with  lessening  ability  on  the  part  of  the  skeletal  muscles  to  bear 
it  and  of  the  heart  to  carry  on  the  circulation,  and  the  disproportion 
between  the  burden  and  the  ability  to  bear  it  increases  with  advancing 
years.  Visceral  fat  accumulations  occur,  also  fatty  changes  in  the  myo- 
cardium and  vessels.  Obese  persons  in  early  middle  life  bear  the  acute 
infections  and  especially  enteric  fever  badly.  Very  often  the  fat  accumu- 
lations are  largely  local,  as  in  the  mamma?,  abdomen,  and  hips  in  women, 
or  in  the  abdomen,  abdominal  walls,  and  omentum  in  men  of  sedentary 
life  and  given  to  the  pleasures  of  the  table. 


27 


418  MEDICAL  DIAGNOSIS. 


III. 

BONES;    JOINTS;    MUSCULATURE;  POSTURE,    ATTITUDE,   AND 
GAIT;    POSTURE    AND    MOVEMENTS    OF    INFANTS. 

BONES. 

The  skeleton  determines  the  stature  and  frame  of  the  individual.  As 
has  been  already  pointed  out  the  normal  limits  of  variation  in  the  meas- 
urements of  the  bony  framework  are  very  wide.  Excess  in  either  direc- 
tion, as  in  gigantism  or  dwarfism,  is  pathological  and  has  been  ascribed  to 
derangements  of  the  functions  of  the  pituitary  body. 

Average  Height  in  Males  and  Females  at  Different  Periods  of  Life. — Quetelet. 

Males.  Females. 

New-born 50.0  cm.  20.00  in.  49.4  cm.  19.76  in. 

1st  year 69.8  cm.  27.92  in.  69.0  cm.  27.60  in. 

2nd  year 79.1cm.  31.64  in.  78.1cm.  31.24  in. 

3rd  year 86.4  cm.  34.56  in.  85.4  cm.  34.16  in. 

4th  year 92.7  cm.  37.08  in.  91.5  cm.  36.60  in. 

5th  vear 98.7  cm.  39.48  in.  97.4  cm.  38.96  in. 

6th  year 104.6  cm.  41.84  in.  103.1  cm.  41.24  in. 

7th  year 110.4  cm.  44.16  in.  108.7  cm.  43.48  in. 

8th  year 116.2  cm.  46.48  in.  114.2  cm.  45.68  in. 

9th  year 121.8  cm.  48.72  in.  119.6  cm.  47.84  in. 

10th  year 127.3  cm.  50.92  in.  124.9  cm.  49.96  in. 

15th  year 151.3  cm.  60.52  in.  148.8  cm.  59.52  in. 

20th  year 167.0  cm.  66.80  in.  157.S  cm.  63.12  in. 

25th  year 16S.2  cm.  67.28  in.  157.4  cm.  62.96  in. 

30th  year 168.6  cm.  67.44  in.  158.0  cm.  63.20  in. 

40th  year 168.6  cm.  67.44  in.  158.0  cm.  63.20  in. 

60th  year. 167.6  cm.  67.04  in.  157.1  cm.  62.84  in. 

70th  year 166.0  cm.  66.40  in.  155.6  cm.  62.24  in. 

There  is  a  constant  relationship  in  healthy  persons  between  the  mus- 
cular development  and  the  size  and  strength  of  the  bones.  In  puny  individ- 
uals with  small  and  flabby  muscles  the  skeleton  is  usually  more  or  less 
under-developed.  In  this  nutritional  relationship  between  the  muscles 
and  the  bones  the  muscles  constitute  the  controlling  factor.  In  a  similar 
manner  the  bony  walls  of  the  cranium  and  thorax  undergo  changes  corre- 
sponding to  changes  in  the  viscera  which  they  contain. 

Thorax. — In  bed-ridden  individuals  and  those  suffering  from  wasting 
diseases  the  involution  of  the  lungs  from  diminished  functional  activity  or 
their  diminution  in  size  from  pathological  changes  causes  alterations  in 
the  shape  and  contour  of  the  thorax,  which  tends  to  assume  permanently 
the  expiratory  form;  while  an  active  life  in  the  open  air  by  increasing 
the  volume  of  the  lungs  modifies  the  chest,  which  under  these  circumstances 
tends  to  assume  permanently  the  inspiratory  form.  Analogous  changes 
in  the  chest  result  from  lesions  which  increase  the  volume  of  the  thoracic 
viscera,  as  in  pulmonary  emphysema  and  great  cardiac  enlargement. 
The  point  for  the  student  to  bear  in  mind  is  that  many  general  and  local 
changes  in  the  form  of  the  chest  are  primarily  due  to  visceral  disease  and 
not  to  disease  of  the  bones.     Some  of  these  are  more  marked  when  the 


SYMPTOMS  AND  SIGNS:   JOINTS.  419 

visceral  disease  takes  place  early  in  life,  as  in  precordial  prominence  and  the 
development  of  Harrison's  furrows,  others  late  in  life,  as  in  fibroid  phthisis 
and  emphysema.  There  are,  however,  exceptions  to  this  general  state- 
ment, an  example  of  which  is  to  be  found  in  the  changes  of  the  shape  of  the 
chest  which  result  from  disease  of  the  spine,  as  kyphosis. 

Cranium. — The  skull  may  be  abnormal  in  size  and  shape  either  as 
the  result  of  arrest  of  development  of  the  brain  with  or  without  malfor- 
mation, or  as  the  result  of  pathological  increase  in  the  size  of  the  brain. 
The  short  diameters  and  peculiar  shape  of  the  head  of  the  microcephalic 
idiot  and  the  globe-like  cranium  of  chronic  hydrocephalus  developing  at 
birth  or  in  early  infancy  with  its  wide  sutures,  open  fontanelles,  and  card- 
like thinness  of  the  bones,  are  examples  of  the  influence  exerted  by  changes 
in  the  soft  parts  upon  the  bony  walls  containing  them. 

Skeletal  Changes. — The  bones  themselves  undergo  pathological 
changes.  These  changes  may  be  general  or  local.  In  acromegaly  there 
is  hypertrophy  of  the  bones  of  the  hands,  feet,  and  face,  especially  the 
inferior  maxilla.  The  clavicles,  sternum,  and  in  some  instances  the  long 
bones  of  the  extremities  also  participate  in  the  over-growth.  In  osteitis 
deformans  or  Paget's  disease  there  is  thickening  of  the  bones  of  the 
skull  and  changes  in  those  of  the  face,  the  outline  of  which  becomes  tri- 
angular with  the  apex  at  the  chin;  the  long  bones  are  involved  and  become 
deformed.  In  rickets,  a  disease  of  childhood,  the  head  is  large  and  square, 
the  forehead  prominent,  the  anterior  fontanelle  open,  the  epiphyses  of 
the  long  bones  are  enlarged,  nodules  develop  at  the  junction  of  the  ribs 
with  their  cartilages.  Changes  in  the  shape  of  the  chest  and  protrusion 
of  the  sternum  cause  the  deformity  known  as  chicken  or  pigeon  breast. 
The  spine  is  curved,  the  clavicle  bent,  the  pelvis  deformed,  and  the  long 
bones  of  the  lower  extremities  show  deformity.  Rachitic  children  are  often 
bow-legged;  those  who  reach  maturity  are  under-sized.  Osteomalacia  is 
characterized  by  resorption  of  trie  lime  salts.  The  bending  of  the  softened 
bones  under  the  action  of  gravity  and  muscular  tension  gives  rise  to 
extraordinary  deformities.  These  affect  the  spine,  thorax,  pelvis,  and  long 
bones.  In  some  instances  the  superficial  bones  crepitate  upon  pressure 
and  can  be  indented  by  the  finger.  They  are  readily  fractured  and  this 
accident  may  follow  a  trifling  fall  or  blow  or,  in  the  case  of  the  femur  or 
humerus,  result  from  the  muscular  force  exerted  in  turning  in  bed.  Pul- 
monary OSTEO- ARTHROPATHY — OSTEO-ARTHROPATHIE  HYPERTROPHIAXTE 
pxkumonique  of  Marie— a  condition  encountered  in  certain  chronic  dis- 
eases of  the  lungs  and  pleura,  is  characterized  by  bulbous  enlargement  of 
the  terminal  phalanges  of  the  fingers  and  toes  and  of  the  distal  epiphyses 
of  the  bones  of  the  upper  and  lower  extremities.  The  finger-nails  are 
hypertrophied  and  strongly  incurved.  The  bones  of  the  head  and  face  are 
not  affected. 

JOINTS. 

There  are  affections  of  the  joints  which  lie  on  the  border  line  between 
surgery  and  medicine.  To  the  former  belong  traumatic  and  operative 
conditions;  to  the  latter  lesions  arising  in  consequence  of  various  consti- 
tutional affections.     Commonly  the  question  of  diagnosis  first  rests  with 


420  MEDICAL  DIAGNOSIS. 

the  medical  clinician.  Those  joint  affections  which  properly  come  within 
the  scope  of  internal  medicine  may  be  comprehensively  described  as  the 
medical  arthropathies.  The  large  and  small  joints  may  be  affected. 
The  chief  symptoms  are  pain,  especially  upon  movement,  impairment  of 
function,  and  the  signs  of  inflammation  or  disorganization,  namely,  changes 
in  color,  size,  and  shape.  The  requisites  to  the  proper  examination  of  a 
diseased  joint  are  a  knowledge  of  the  local  anatomy  and  pathology  and  of 
the  constitutional  diseases  in  which  joint  affections  occur. 

Pain. — Pain  is  an  important  symptom.  It  may  be  spontaneous.  More 
commonly  it  is  caused  by  movement.  Pain  upon  pressure  occurs  in  acute 
forms  of  arthritis  and  is  often  intense.  Pain  is  commonly  referred  to  the 
affected  joint,  sometimes  to  a  distant  part,  as  the  pain  in  the  knee  in  hip- 
joint  disease.  In  consequence  of  the  freer  movement  permitted  by  mus- 
cular relaxation  during  sleep  the  pain  is  worse  at  night.  There  may  be 
insomnia,  or  sleep  may  from  time  to  time  be  broken  by  sudden  agonizing 
pain.  This  is  especially  the  case  in  tuberculous  joint-disease.  The  patient 
very  often  awakes  with  a  sharp  cry  of  pain.  The  pain  in  myalgia  and 
various  forms  of  neuritis  is  frequently  attributed  to  diseases  of  the  joint; 
upon  movement  the  pain  is  found  not  to  involve  the  joint,  but  other  struct- 
ures, and  the  joint  is  neither  tender  nor  swollen.  In  chronic  joint  affections 
movement  is  sometimes  attended  by  a  sensation  of  grating  or  crepitus,  or 
there  may  be  a  catching  sensation  attended  svith  crackling  sometimes 
audible  at  a  distance. 

Color. — The  color  of  the  joint  in  acute  inflammation  is  pinkish  or  red; 
when  intense  it  is  cyanotic  or  dusky.  When  there  is  marked  periarticular 
oedema  the  overlying  skin  is  pale. 

Changes  in  Size. — In  acute  inflammation  the  joints  are  usually 
enlarged.  This  enlargement  is  attended  with  alteration  in  the  contour. 
These  changes  are  due  to  effusion,  which  may  be  articular  or  periarticular. 
The  former  may  be  serous,  purulent,  or  hemorrhagic.  The  latter  may 
be  cedematous  or  exudative.  These  conditions  are  often  combined.  In 
chronic  arthritis  there  is  infiltration  of  the  tissues  entering  into  the  for- 
mation of  the  joint.  Enlargement  due  to  effusion  within  the  joint  may 
be  recognized  by  palpation,  especially  in  large  joints.  In  the  knee  the 
patella  floats.  Pounded  local  swellings  fluctuating  upon  palpation  may 
indicate  the  distention  of  the  synovial  sac.  Enlargement  may  be  due 
to  changes  in  the  ends  of  the  bones. 

Irregular  diminution  in  the  size  may  occur  in  chronic  disease  of  the 
joints,  as  rheumatoid  arthritis  or  other  diseases  characterized  by  resorp- 
tion or  retrogressive  processes.  Not  only  the  tissues  of  the  joint  but  the 
periarticular  structures  undergo  atrophy  and  subluxations  occur,  or  there 
may  be  diminution  in  the  soft  parts  with  thickening  of  the  bones.  All 
these  processes  are  associated  with  changes  in  contour. 

The  posture  is  of  importance.  In  forms  of  acute  arthritis,  flexion  or 
semi-flexion  and  immobility  are  present — the  attitude  of  least  tension  and 
therefore  of  least  pain.  The  mobility  of  the  joint  is  determined  by  passive 
movement.  Fixation  may  be  voluntary  because  it  relieves  pain.  It  may 
result  from  muscular  spasm  or  large  effusion.  Sudden  locking  of  a  joint, 
especially  the  knee,   may  be  due  to  floating  cartilages  or  "joint  mice" 


SYMPTOMS  AND  SIGNS:   JOINTS. 


421 


becoming  arrested  between  the  anterior  surface  of  the  bones  and  the  cap- 
sular ligament.  In  late  cases  the  immobility  is  due  to  ankylosis,  which  may 
be  adhesive,  fibrous,  or  bony.  Movement  may  be  limited  or  prevented  by 
the  development  of  osteophytes  in  the  region  of  the  joints.  Crepitus  may 
be  detected  upon  palpation. 

Any  of  the  joints  may  be  involved  in  general  diseases.  The  knee, 
hip,  and  shoulder  are  especially  important,  because  of  the  frequency  with 
which  they  are  implicated,  the  disabling  results,  and  the  tendency  to 
disorganization   and   ankylosis. 

The  medical  arthropathies  are  inflammatory  or  infective,  degenera- 
tive, and  neuropathic. 

Primary  Arthritis. — Simple  acute  synovitis  with  effusion  is  very 
common  especially  in  adolescents  and  young  adults.     It  most  frequently 


Fig.  171.— Tophaceous  deposits  in  gout. 


involves  the  knee-joint.  Traumatism  and  sudden  chilling  are  causes.  Some 
of  the  cases  appear  to  be  monarticular  rheumatism  with  trifling  fever. 
There  is  marked  tendency  to  recurrence  and  chronicity. 

Rheumatic  Fever. — The  affected  joints  are  swollen,  hot,  usually 
slightly  reddened,  and  painful  upon  motion.  The  amount  of  swelling  is 
variable.  The  intra-articular  effusion  is  usually  slight  or  moderate,  the 
periarticular  oedema  being  commonly  marked.  When  the  wrists  and 
ankles  are  implicated  there  is  marked  swelling  of  the  hands  and  feet.  The 
joint  effusion  of  rheumatic  fever  is  fugacious.  The  tendency  to  rapidly  sub- 
side in  one  joint  and  develop  in  others  is  characteristic.  The  process  is 
rarely  limited  to  a  single  joint.  Any  joints  may  be  affected,  but  the  knees, 
ankles,  and  wrists  are  especially  liable  to  the  rheumatic  inflammation. 

Chronic  Rheumatism.  — This  term  is  applied  to  a  chronic  condition 
in  which  the  joints  are  painful,  stiff,  moderately  swollen,  and  but  slightly 
deformed.  It  is  common  in  individuals  who  have  been  much  exposed  to 
the  vicissitudes  of  the  weather  or  have  lived  in  damp  places.  Its  etiological 
affinity  to  rheumatic  fever  may  well  be  questioned.  Some  of  the  cases 
described  under  this  term  are  undoubtedly  subacute  forms  of  rheumatoid 


422  MEDICAL  DIAGNOSIS. 

arthritis.  In  others  the  process  is  gouty.  Cases  of  adhesive  chronic  ar- 
thritis have  been  described  under  the  term  chronic  rheumatism.  Very 
fat  persons  with  small  bones  at  or  beyond  middle  life  often  suffer  from 
painful  knees.  There  is  nothing  to  indicate  gouty  or  rheumatic  disease 
and  no  sign  of  actual  inflammation.  The  pain  is  brought  on  by  standing 
or  walking  and  is  often  intense.  There  may  be  tenderness.  The  condition 
is  mechanical,  the  bearing  surface  being  inadequate  to  the  weight  of  the 
body.     Other  articulations  are  not  involved. 

Gout. — This  form  of  arthritis  is  due  to  the  precipitation  of  salts  of 
uric  acid  in  the  joint  structures.  The  metatarsophalangeal  joint  of  the 
great  toe  is  first  and  most  commonh7  affected,  but  other  joints  and  espe- 
cially the  knee  and  ankle  are  occasionally  involved.  There  is  rapid  swell- 
ing with  heat,  tension,  and  a  bluish-red  glistening  skin. 

Arthritis  Deformans. — Implication  of  the  joints  is  usually  symmetri- 
cal though  monarticular  forms  occur.  First  one  or  two  joints  only  are 
involved.      Gradually   others   are    implicated   and   cases   occur   in    which 


Fig.  172.— Heberden's  nodes  (page  301.  Vol.  II). 

all  the  joints  suffer.  Attacks  of  acute  inflammation  are  succeeded  by 
periods  of  quiescence,  but  after  each  attack  the  evidences  of  disintegra- 
tion are  more  pronounced.  The  ligaments  of  the  small  joints,  especially 
of  the  hands,  are  relaxed  and  the  bones  of  the  phalanges  under  the  action 
of  gravity  very  often  form  an  obtuse  angle  with  the  metacarpal  bones 
toward  the  ulnar  side.  Atrophic  changes  in  the  muscles  and  other 
structures  relating  to  the  affected  joints  occur  in  extreme  cases. 
All  the  articulations  may  become  ankylosed  and  the  patient  bed- 
ridden and  almost  completely  helpless.  There  are  partial  or  mon- 
articular forms  which  occur  in  old  persons.  The  spine  may  be 
involved — spondylitis  deformans — with  pain,  anaesthesia,  and  muscular 
atrophy.  In  other  cases  the  spine  is  involved  together  with  the  shoul- 
der- and  hip-joints  and  nervous  symptoms  are  less  prominent.  Kyphosis 
and  fixation  occur. 

Infective  Arthritis.  —  Inflammatory  joint  affections  frequently 
develop  during  convalescence  from  the  acute  infectious  diseases.  One 
or  more  joints  show  signs  of  inflammation.  This  form  of  arthritis 
is  frequent  after  scarlet  fever  and  sometimes  occurs  in  cerebrospinal 
meningitis,     the    variolous    diseases,     dengue,    and    enteric     fever.      An 


SYMPTOMS  AXD  SIGNS:   JOINTS. 


423 


-Jefferson  Hospital. 


acute  arthritis  going  on  to  suppuration  with  disorganization  of  the  joint 
occurs  in  septic  conditions.  The  joint  affection  which  accompanies 
osteomyelitis  is  attended  with  high 
fever  and  constitutional  disturbances. 

Gonorrhoeal  Arthritis.  —  Fre- 
quently one  joint  only  is  involved, 
sometimes  several.  The  knee,  wrist, 
and  ankle  frequently  suffer.  Teno- 
synovitis may  occur.  Fever  is 
moderate  or  absent,  or  there  is 
great  pain  on  movement,  and  the 
joint  affection  is  frequently  per- 
sistent   and    disabling. 

Arthritis  in  Hemorrhagic  Dis= 
eases. — Acute  arthritis,  more  or  less 
intense  and  suggestive  of  the  joint 
affection  of  rheumatic  fever,  occurs 
in  forms  of  purpura  and  in  haemo- 

....  x      •         i         i  •     •  ,1  blG.  173. — Arthritis  deformans 

phiha.      It  is  the  larger  joints  that 

are    chiefly   affected.      Intra-articular   hemorrhage   may   occur.     Arthritis 

is    an    occasional    complication    of    scurvy. 

Tuberculous  Arthritis.— Tuber- 
culous joint  disease  is  common.  It 
is  often  secondary  to  tuberculosis  of 
the  bones.  It  was  formerly  known 
as  white  swelling — tumor  albus.  The 
process  is  comparatively  subacute 
but  tends  to  permanent  disorgani- 
zation. Tuberculous  joints  are 
usually  swollen.  In  the  course  of 
the  disease  chronic  inflammatory 
infiltration  takes  place  into  the  cap- 
sule, ligaments,  and  periarticular 
connective  tissue.  Caseation  and 
softening  result  in  abscess  formation 
and  burrowing  along  the  lines  of 
least  resistance.  Tortuous  fistulous 
passages  occur.  The  hip.  elbow, 
knee,  and  wrist  are  frequently 
affected.  There  may  be  evidences 
of  tuberculosis  in  the  lungs  or  else- 
where.  .More  commonly  the  process 
is  limited  to  the  affected  joint  and 
adjacent  structures. 

Syphilis. — The  acute  joint  affec- 
tion  of  new-born  infants  sometimes 
regarded  as  rheumatic  is  mostly  syphilitic  It  is  a  form  of  primary  exuda- 
tive arthritis  with  fibrous  thickening  of  the  capsule  Gummatous  inflam- 
mation in  the  neighboring  tissues  may  involve  a  joint    by  extension.     In 


Via.  174 — Arthritis  deformans  with  extreme  ulnar 
deformity. — JefTtr.-.on  Hospital. 


424 


MEDICAL  DIAGNOSIS. 


acquired  syphilis  subacute  synovitis  occasionally  occurs  during  the  period 
of  eruption.  The  sternoclavicular  joint  shows  a  peculiar  liability.  In 
late  syphilis,  forms  of  chronic  arthritis,  the  result  of  gummatous  infiltration 

of  the  tissues  forming  the  joint,  occur. 
Actinomycosis. — The  joints  are 
sometimes  involved  by  metastasis. 
In  other  cases  they  are  invaded  by 
extension,  as  when  the  disease  reaches 
the  articulations  of  the  cervical  verte- 
brae or  when  prevertebral  actino- 
mycosis attacks  the  spine  or  the 
disease  extends  from  the  thorax  to 
the  sternoclavicular  joints  or  from 
the  abdomen  to  the  hip-joints. 

Neuropathic  Joint  Affections. — 
Hysteria  especially  may  simulate  dis- 
ease of  the  joints.  The  impairment 
of  function  is  caused  by  contracture 
of  muscles.  Pain  is  more  diffuse  and 
spontaneous  than  in  actual  arthritis. 
The  patient  avoids  movement  and 
does  not  cooperate  in  the  examination. 
The  signs  of  effusion,  inflammation, 
and  erosion  are  lacking.  These  are  the  cases  in  which  spontaneous  cures 
sometimes  occur  under  profound  mental  suggestion.  In  some  instances, 
from  prolonged  disuse,  infiltration,  and.  thickening  of  the  periarticular 
tissues,  false  ankylosis  and  atrophy  of  the  associated  muscles  occur.  It 
is  important  to  bear  in  mind  that  hysterical  symptoms  may  be  superadded 
to  those  of  actual  joint  disease.  The  differential  diagnosis  between 
traumatic  joint  disease  and  a  hysterical  joint  in  traumatic  hysteria  is 
occasionally  attended  with  difficulty.     Vasomotor  changes  with  swelling. 


Fig.    175. — Gonorrhoeal  arthritis. — Pennsylvania 
Hospital. 


Fig.  176. — Ataxic  knee-joint. — Young. 


tension,  and  redness  sometimes  occur  and  the  surface  temperature  maj7 
be  two  or  three  degrees  higher  than  that  in  the  axilla.  These  symp- 
toms are  not  associated  with  fever  or  the  evidences  of  constitutional 
disturbance  and  are  commonly  transitory  and  recurrent. 


SYMPTOMS  AND  SIGNS:   MUSCULATURE.  425 

More  important  are  the  changes  that  take  place  in  connection  with 
certain  diseases  of  the  nervous  system — Charcot's  joints,  tabetic 
joints — particularly  locomotor  ataxia,  syringomyelia,  less  frequently  in 
anterior  poliomyelitis  and  other  diseases  of  the  spinal  cord.  The  joint 
affection  in  tabes  is  much  more  common  in  the  joints  of  the  lower  extrem- 
ities, especially  the  knee,  less  frequent  in  the  hip  and  ankle;  that  of 
syringomyelia  is  by  far  more  common  in  the  upper  extremities.  The 
derangements  are  primarily  trophoneurotic.  The  process  is  frequently 
monarticular.  The  pathological  and  clinical  changes  correspond  to  those 
of  the  milder  and  graver  forms  of  rheumatoid  arthritis.  In  the  more 
severe  forms  they  differ  in  suddenness  of  onset,  intra-articular  effusion, 
and  a  rapid,  disintegrating  course  without  pain.  Subluxations  and 
luxations  take  place.  When  the  tarsal  articulations  are  implicated 
flat-foot  occurs  with  characteristic  deformities — the  tabetic  foot. 

MUSCULATURE. 

Diagnostic  criteria  of  importance  are  obtained  by  an  examination  of 
the  condition  of  the  muscles.  Wide  variations  in  the  bulk  and  tonicity 
of  the  general  musculature  is  encountered  within  the  limits  of  health. 
These  variations  depend  largely  upon  the  hereditary  constitution,  occu- 
pation, and  bodily  activities  of  the  individual  and  are  not  of  diag- 
nostic significance.  Trophic  derangements  result  in  hypertrophy  and 
atrophy. 

Hypertrophy. — True  hypertrophy,  that  is  to  say,  increased  volume 
with  increase  of  power,  is  exceedingly  rare.  It  occurs  in  Thomsen's  disease. 
Congenital  hypertrophia  musculorum  vera  has  been  described.  Patho- 
logical increase  in  the  muscles  is  almost  always  a  pseudohypertrophy. 
The  abnormal  volume  is  not  due  to  an  increase  in  the  contractile  tissue 
but  to  a  proliferation  of  the' connective  tissue  and  fat.  This  muscular 
dystrophy  occurs  in  its  most  pronounced  form  in  the  so-called  pseudo- 
hypertrophic muscular  paralysis  of  childhood,  and  very  rarely  in  some 
of  the  affected  muscles  in  certain  cases  of  chronic  progressive  muscular 
atrophy. 

Atrophy. — Atrophy  of  the  muscles  may  be  simple  or  inactivity  atrophy 
— the  atrophy  of  disuse.  The  affected  muscles  are  diminished  in  size,  soft, 
and  flaccid;  there  is  loss  of  the  contractile  substance;  the  interstitial  con- 
nective tissue  is  not  increased.  This  form  of  atrophy  occurs  in  certain 
forms  of  paralysis,  and  supervenes  upon  mechanical  fixation  of  a  limb  or 
the  prolonged  immobility  resulting  from  joint  pain  or  ankylosis.  Com- 
plete loss  of  movement  usually  gives  rise  to  a  high  grade  of  simple  atrophy. 
Atrophy  from  disuse  rarely  attains  the  degree  often  soon  in  the  degenera- 
tive atrophies.  In  simple  atrophy  there  is  general  diminution  in  the  volume 
of  the  affected  limb,  while  in  the  degenerative  atrophies  single  muscles  or 
groups  of  muscles  are  exclusively  or  chiefly  involved.  The  electrical  re- 
actions in  simple  atrophy  are  quantitatively  and  not  qualitatively  changed. 
The  nutritional  muscular  atrophy  which  occurs  in  starvation,  in  the  course 
of  acute  infections,  and  in  the  chronic  wasting  diseases  must  be  regarded 
as  a  diffuse  form  of  simple  atrophy. 


426 


MEDICAL  DIAGNOSIS. 


Myoidema. — This  phenomenon  consists  in  a  sudden  contraction  of 
muscular  fibres  when  smartly  tapped  with  the  finger  or  hammer,  with 
transitory  humping  at  the  point  of  impact.  It  is  manifested  in  muscles 
that  are  undergoing  rapid  wasting,  especially  in  phthisis,  and  is  as  a  rule 
best  developed  in  the  muscles  of  the  chest. 

Degenerative  Atrophy. — The  degenerative  muscular  atrophies,  which 
are    characterized    not    only    by    loss    of    contractile    substance    but   also 


Fig.  177. — Pseudohypertrophic  muscular  paralysis.      Brothers,  eight  and  ten  years  old 
lordosis;    b,  showing  atrophy  of  back  and  enlarged  calves.— Rotch. 


a,  showing  the 


by  an  overgrowth  of  the  interstitial  connective  tissue,  may  be  referred  to 
two  groups:  (a)  the  progressive  muscular  atrophies,  and  (b)  the  atrophic 
paralyses. 

The  progressive  muscular  atrophies  may  be  divided  into  myopathic, 
peripheral,  and  central  or  nuclear  according  to  the  seat  of  the  essential 
pathological  process,  which  may  primarily  involve  the  muscles,  or  result 
from  an  acute  or  chronic  peripheral  neuritis,  or  from  degenerative  changes 
in  the  ganglion  cells  of  the  anterior  horns  of  the  cord,  or  the  motor 
nuclei  of  the  brain.  There  is  progressive  atrophy  of  individual  muscles 
and  muscle  groups;  diffuse  atrophy  of  an  entire  limb  occurs  only  in 
advanced  stages;  the  strength  of  the  muscles  is  diminished  in  proportion 
to  the  diminution  of  their  volume.    In  this  respect  the  progressive  muscular 


SYMPTOMS  AXD  SIGNS:   MUSCULATURE. 


427 


atrophies  are  in  contrast  with  the  secondary  degenerative  atrophies  which 
follow  the  atrophic  paralyses.  In  the  latter  the  paralysis  comes  first,  the 
atrophy  afterwards.  The  discrimination  between  myopathic,  neural,  and 
nuclear  muscular  atrophies  rests  upon  the  fact  that  in  the  different  forms 
particular  groups  of  muscles  are  affected.  In  the  myopathic  forms  of 
degenerative  atrophy — the  muscular  dystrophies — the  following  principal 
types   occur:      1.   Pseudohypertrophic    muscular   atrophy    of    childhood — 


Fig.  178. — a,  infantile  atrophy  from  improper  feeding  (female  ten  months  old);    b,  recovery  after  three 

months. — Rotch. 

the  so-called  pseudohypertrophic  muscular  paralysis.  2.  The  juvenile 
type  of  Erb — dystrophia  musculorum  progressiva;  the  atrophy  begins  in 
the  shoulder  girdle  and  is  not  preceded  by  pseudohypertrophy.  3.  The 
juvenile  type  of  Leyden-Mobius;  the  atrophy  begins  in  the  lower  extrem- 
ities. This  form  is  closely  allied  to  the  progressive  pseudohypertrophy  of 
childhood.     4.  The  infantile  type  of  Duchenne — the  facio-scapulo-humeral 


Fig.  179. —  General  atrophy  of  the  muscles  in  a  case  of  cerebrospinal  fever;   fifty-fifth  day  of  illness. — Royer. 

typo  of  Landouzy-Dejerine.  This  form  begins  in  the  face.  The  loss  of 
power  in  the  muscles  of  expression  gives  rise  to  the  characteristic  facii  S 
myopathica.  The  eyes  can  no  longer  be  completely  closed,  the  checks  are 
sunken,  the  lips  thickened  and  everted,  speech  is  impaired,  and  the  ordinary 
changes  in  the  countenance  in  laughter  and  crying  are  not  seen.  The 
myopathic  atrophies  are  commonly  hereditary  and  almost  always  show 
themselves  in  early  life  Neural  atrophy  begins  commonly  in  the  under 
extremities  in  the  distribution  of  the  peroneal  nerve-  the  peroneal  type 
of  Charcot  and  Marie — and  may  lead  to  the  development  of  club-foot, 
usually  pes  equinua  or  pes  equinovarus.     It  differs  from  other   forms  of 


428  MEDICAL  DIAGNOSIS. 

myopathic  atrophy  in  the  frequent  occurrence  of  derangements  of  sensation; 
pain,  and  fibrillary  contractions  and  in  the  occasional  presence  of  the  reaction 
of  degeneration.  In  many  cases  of  peripheral  neuritis  the  affected  muscles 
undergo  degenerative  atrophy.  Spinal  or  nuclear  atrophy  usually  first 
shows  itself  in  the  intrinsic  muscles  of  the  hand  and  by  extension  early 
involves  the  tongue,  lips,  palate,  pharynx,  and  larynx,  giving  rise  to  the 
picture  of  bulbar  paralysis.  Fibrillary  contractions  of  the  muscles  are 
common  and  reactions  of  degeneration  occur.  The  disease  develops  almost 
exclusively  in  adult  life  and  is  not  hereditary. 

The  Atrophic  Paralyses. — Ihe  muscles  undergo  secondary  degenera- 
tive atrophy.  The  lesion  which  interferes  with  the  transmission  of  motor 
impulses  at  the  same  time  interrupts  trophic  influences  to  the  muscle. 
The  paralysis  shows  itself  first  and  is  followed  by  atrophy,  which  in  the 
course  of  some  weeks  becomes  marked  and  often  reaches  a  very  high  grade. 
The  reactions  are  those  of  degeneration.  In  this  form  of  degenerative 
atrophy  fibrillary  contractions  are  frequently  present. 

THE   POSTURE,   ATTITUDE,   AND   GAIT. 

Posture. 

Patients  who  are  very  ill  of  an  acute  disease  or  in  the  advanced  stages 
of  chronic  disease  are  usually  seen  in  bed;  those  suffering  from  trifling 
affections  or  in  whom  the  symptoms  of  grave  disease  are  not  yet  urgent 
or  disabling  continue  to  be  about,  but  this  is  not  always  the  case.  Whether, 
on  the  one  hand,  a  patient  remains  up  and  about,  endeavoring  to  attend 
to  his  ordinary  duties  while  suffering  from  serious  symptoms  or,  on  the 
other  hand,  betakes  himself  to  bed  upon  the  occurrence  of  trifling  symp- 
toms is  often  a  matter  of  temperament.  It  is  not  uncommon  for  a  patient 
suffering  from  enteric  fever  to  come  to  the  consultation  room  or  dispensary 
in  the  second  week  of  the  attack  with  a  temperature  of  104°  F.  (40°  C.)  and 
a  well-developed  rose  rash — walking  typhoid.  Patients  who  realize  their 
condition  very  often  feel  compelled  by  circumstances  to  continue  the 
discharge  of  a  daily  duty  or  are  buoyed  up  by  the  hope  of  speedy  improve- 
ment, and  again  there  are  acute  diseases  which  run  a  favorable  course  which 
begin  with  urgent  and  distressing  symptoms.  The  physician  usually 
finds  those  patients  in  bed  who  have  high  fever,  prostration,  or  a  general 
sense  of  serious  illness,  and  those  who  suffer  from  dyspnoea,  pain,  vertigo, 
and  other  symptoms  intensified  by  movement  or  exertion.  In  meningitis, 
peritonitis,  rheumatic  fever,  pericarditis,  typical  croupous  pneumonia,  and 
in  well-developed  cases  of  the  acute  exanthemata  it  is  impossible  for  the 
patient  to  be  out  of  bed.  It  is  to  be  noted,  however,  that  upon  the  appear- 
ance of  the  eruption  in  the  variolous  diseases  the  symptoms  of  onset  often 
undergo  such  an  amelioration  that  the  patient  regards  himself  as  conva- 
lescent and  insists  upon  getting  out  of  bed. 

Decubitus  is  the  posture  of  the  patient  in  bed.  It  is  of  diagnostic 
importance.  It  is  in  moderate  illness,  as  in  health,  easy  and  unconstrained. 
The  patient  arranges  the  bed-clothes,  changes  his  position  when  it  has 
become    uncomfortable,    lies    naturally    upon    his    back — active    dorsal 


SYMPTOMS  AND  SIGNS:   POSTURE.  429 

decubitus — or  turns  upon  the  side — active  lateral  decubitus.  The 
posture  of  weak,  helpless,  or  unconscious  individuals  in  bed  is  wholly  dif- 
ferent. The  muscles  play  little  part  in  maintaining  the  position. 
The  relaxed  body  yields  to  the  law  of  gravity  and  sinks  toward  the 
foot  of  the  bed,  where  it  remains.  The  patient,  even  when  his  breathing 
is  hindered  and  his  position  is  uncomfortable,  is  unable  to  change  it.  The 
attendants  must  again  and  again  lift  him  upon  the  pillows.  The  condition 
is  wholly  passive — passive  dorsal  decubitus.  In  rare  instances  the 
patient  in  this  state  lies  upon  the  side — passive  lateral  decubitus. 

Forced  or  imperative  attitudes  are  very  characteristic  of  certain 
diseases.     The  following  are  the  most  important : 

The  Dorsal  Posture. — In  acute  peritonitis,  whether  general  or  local, 
the  patient  lies  upon  the  back  with  the  thighs  flexed  upon  the  abdomen 
and  the  legs  upon  the  thighs.  Movement  is  avoided  and  the  patient  shrinks 
from  pressure  upon  the  abdomen. 

The  Reclining  Dorsal  or  the  Sitting  Posture. — In  diseases  attended 
with  difficult  respiration,  especially  certain  diseases  of  the  respiratory 
and  circulatory  organs  and  the  kidneys,  the  patients  are  forced  to  assume 
a  semi-upright  posture  on  the  bed-rest  or  propped  up  with  pillows,  or  to 
sit  upright.  Attempts  to  lie  flat  in  bed  increase  the  difficulty  of  respiration. 
The  sitting  position  relieves  it  by  favoring  the  action  of  the  accessory 
respiratory  muscles,  especially  when  the  arms  are  used  to  elevate  and  fix 
the  shoulders.  In  the  case  of  peritoneal  effusions  the  respiratory  move- 
ment of  the  diaphragm  is  less  interfered  with  in  the  sitting  posture  unless 
the  effusion  be  very  large,  in  which  case  the  abdomen  is  somewhat  com- 
pressed by  the  thighs.  This  attitude,  furthermore,  favors  the  return  of  the 
venous  blood  from  the  brain.  For  this  reason  high  grades  of  dyspnoea 
are  described  under  the  term  orthopngea.  When  the  difficulty  of  respira- 
tion is  extreme  the  patients  can  no  longer  remain  in  bed  but  are  obliged  to 
sit  upright,  fixing  the  shoulders" by  placing  the  hands  upon  the  side  of  the 
chair  or  its  arms  in  order  to  facilitate  the  use  of  the  accessory  muscles  and 
to  relieve  the  abdomen  from  the  pressure  of  the  thighs.  The  distress  is 
also  to  some  extent  relieved  by  the  gravitation  of  venous  blood  and  the 
fluid  of  general  dropsical  effusions  to  the  lower  extremities.  Orthopncea 
is  present  during  the  paroxysms  of  asthma,  in  extreme  cases  of  valvular 
disease  of  the  heart  with  ruptured  compensation,  in  large  pleural  and  peri- 
cardial effusions,  in  massive  peritoneal  effusions,  and  in  general  anasarca, 
which  may  be  cardiac  or  renal  but  is  very  often  cardiorenal.  It  occurs 
also  in  advanced  pulmonary  emphysema  and  in  obstructive  diseases  of 
the  larynx,  as  croup  and  diphtheria.  Except  in  extreme  cases  it  is  usually 
paroxysmal,  the  attack  being  brought  on  by  movement,  coughing,  conver- 
sation, or  other  exertion. 

Lateral  Postures.  —  Patients  suffering  with  unilateral  disease  of  the 
thoracic  Organs  very  often  lie  upon  the  affected  side.  This  is  especially 
the  case  in  large  pneumonic  exudates,  pleural  and  pericardial  effusions,  and 
other  conditions  which  greatly  diminish  the  respiratory  surface  of  the 
affected  lung.  In  this  posture  the  respiratory  excursus  of  the  sound  side 
is  not  hampered  by  the  weight  of  the  diseased  organs.  In  painful  condi- 
tions, however,  the  patients  sometimes  lie  upon  the  sound  side.     In  acute 


430  MEDICAL  DIAGNOSIS. 

fibrinous  pleurisy  the  pain  of  which  is  greatly  intensified  by  breathing, 
the  lateral  decubitus  upon  the  affected  side  is  assumed  by  preference  because 
the  weight  of  the  body  somewhat  diminishes  the  respiratory  excursus  of 
that  side  of  the  chest.  Patients  suffering  from  heart  disease  and  many 
individuals  in  good  health  lie  more  comfortably  upon  one  side  than  upon 
the  other;  sometimes  the  right  side  is  preferred,  sometimes  the  left.  In 
cardiac  hypertrophy  the  patients  usually  lie  more  comfortably  upon  the 
left  side,  and  in  large  aneurisms  of  the  aorta,  upon  the  affected  side.  Pa- 
tients suffering  from  harassing  cough  in  the  dorsal  position  are  sometimes 
relieved  by  turning  upon  one  side.  This  happens  in  certain  cases  of  uni- 
lateral pulmonary  cavity  and  the  relief  is  obtained  by  turning  upon  the 
affected  side.  The  explanation  of  this  phenomenon  is  purely  physical; 
while  the  patient  lies  upon  his  back  or  upon  the  sound  side  the  secretion 
formed  in  the  cavity  escapes  into  the  bronchus  little  by  little,  causing 
irritation  which  manifests  itself  by  cough,  while,  on  the  other  hand,  if  he 
continues  to  lie  upon  the  affected  side  it  collects  without  producing  reflex 
cough  until  the  cavity  overflows.  The  lateral  decubitus  with  the  thighs 
and  legs  flexed  upon  the  abdomen  and  the  spine  and  neck  strongly  arched 
forward  is  usually  assumed  during  the  pains  of  parturition  and  is  common 
in  hepatic  and  intestinal  colic.  In  acute  cerebrospinal  meningitis  the 
patient  frequently  lies  upon  the  side  with  the  thighs  and  legs  strongly 
flexed  and  the  spine  extended  in  the  position  of  opisthotonos.  In  some 
cases  the  lower  extremities  are  extended — complete  opisthotonos. 

The  ventral  posture  is  sometimes  assumed  in  cases  of  abdominal  pain, 
as  colic,  gastralgia,  or  enteralgia.  The  patient  lies  prone  upon  the  bed 
with  his  face  buried  in  the  pillow.  Tenderness  upon  abdominal  pressure, 
as  in  peritonitis,  renders  this  attitude  impossible.  It  sometimes  affords 
relief  to  the  pain  of  abdominal  aneurism  and  in  certain  cases  of  caries  of 
the  spine.  In  most  cases  of  gastric  ulcer  this  posture  is  avoided  on  account 
of  the  epigastric  tenderness  upon  pressure.  In  some  cases  of  this  disease, 
however,  the  pain  is  relieved  by  the  ventral  decubitus,  probably  because 
the  ulcer  is  so  situated  as  to  escape  in  this  position  the  pressure  of  the 
contents  of  the  stomach.  Patients  suffering  from  headache  very  often 
assume  this  posture. 

Restlessness  in  bed  is  a  very  common  symptom.  The  patient  is  unable 
to  maintain  the  same  position  for  any  length  of  time;  he  tosses  about, 
turns  from  side  to  side,  fusses  at  the  bed-clothes,  and  his  hands  and  feet 
are  in  constant  motion.  Restlessness  may  be  the  manifestation  of  nervous 
irritability  or  of  pain.  It  is  common  in  affections  attended  with  burning 
and  itching  of  the  skin,  as  scarlet  fever  and  urticaria.  It  occurs  also  in 
some  cases  of  shock  and  accompanies  profuse  hemorrhage,  in  which  case 
it  is  attended  with  pallor,  urgent  thirst,  and  rapid,  small  pulse.  In  truth 
the  association  of  restlessness  with  these  symptoms,  occurring  suddenly 
without  visible  bleeding,  warrants  a  provisional  diagnosis  of  internal 
hemorrhage.  The  term  jactitation  is  used  to  designate  a  high  degree  of 
restlessness.  The  patient  tosses  about  violently;  the  constant  efforts  of 
the  attendants  are  necessary  to  keep  him  in  bed.  Jactitation  occurs  in 
maniacal  delirium,  in  cases  of  violent  chorea,  in  which  it  is  accompanied 
by  constant  twitching  of  the  muscles,  as  a  temporary  manifestation  in 


SYMPTOMS  AND  SIGNS:    ATTITUDE. 


431 


some  forms  of  hysteria,  and  in  a  high  degree  during  the  stage  of  clonic 
convulsions  in  epilepsy. 

Opisthotonos,  predominating  tonic  contraction  of  the  spinal  muscles, 
so  that  the  body  rests  upon  the  head  and  heels;  emprosthotonos,  or 
bending  forward  of  the  trunk;  pleuruthotoxus.  arched  lateral  posture; 


Fig.  180. — Opisthotonos  in  a  ease  of  epidemic  cerebrospinal  meningitis. — Royer. 


Fio. 


-Pleurothotui 


t   epidemic   cerebrospinal    meningitis. — Iluyer. 


and  orthotoxos.  in  which  the  trunk  and  neck  are  rigidly  extended  in  a 
straight  line,  are  all  symptoms  that  occur  in  tetanus  and  in  some  cas 
meningitis  and  strychnine  poisoning. 


Attitude. 

The  attitude  and  movements  of  patients  who  are  able  to  be  about 
frequently  convey  important  information  in  regard  to  their  condition. 
The  young  and  the  strong  carry  themselves  erect  and  walk  briskly  and 
firmly;  the  aged  and  feeble  and  those  mentally  depressed  are  bowed  and 
move  slowly  and  with  effort.  The  convalescent  from  a  prostrating  disease 
is  at  first  weak  and  shaky;  he  can  scarcely  stand;  an  hour  in  the  arm-chair 
fatigues  him.     In  a  little  time  he  makes  the  journey  around  his  room  with 


432  MEDICAL  DIAGNOSIS. 

slow  and  uncertain  gait,  and  is  soon  obliged  to  rest.  With  returning 
strength  comes  the  erect  carriage  and  firmer  step.  Modifications  of  atti- 
tude and  gait  constitute  characteristic  symptoms  in  many  diseases.  In 
general  they  are  due  to  skeletal  defects,  as  in  caries  of  the  spine,  hip-joint 
disease,  or  ankylosis  of  the  knee;  derangements  of  the  muscular  power  or 
function,  as  in  pseudohypertrophic  muscular  paralysis,  chorea,  and  the 
shaking  palsies;  derangements  of  the  balance  between  antagonistic  muscle 
groups,  as  in  forms  of  spinal  curvature  and  club-foot;  derangements  of 
coordination,  as  in  cerebellar  disease  and  tabes;  forms  of  paralysis,  as  in 
hemiplegia,  anterior  poliomyelitis;  and  contractures,  as  in  the  cross-legged 
progression  of  children  suffering  from  spastic  paraplegia. 

Station  is  technically  the  ability  to  maintain  the  erect  position  while 
standing.  It  depends  largely  upon  muscular  and  visual  coordination. 
Within  limits  it  is  better  the  wider  the  base  of  support,  hence  the  test  should 
be  made  with  the  feet  parallel  and  the  heels  and  toes  touching,  first  with  the 
eyes  open,  later  with  them  closed.  Hinsdale  found  in  normal  individuals 
of  both  sexes  the  average  oscillation  in  the  above  position,  as  determined 
by  an  instrument  devised  for  the  purpose,  to  be  about  an  inch  in  a  forward 
and  backward  line  and  three-quarters  of  an  inch  laterally.  The  oscilla- 
tion in  children  is  greater  than  that  in  adults.  Upon  closing  the  eyes  it  is 
increased  about  50  per  cent.  In  diseases  characterized  by  impairment  of 
the  power  of  coordination,  as  tabes  and  lesions  of  the  cerebellum,  station 
is  greatly  impaired  and  the  patient  may  be  wholly  unable,  under  the  condi- 
tions of  the  test  and  with  closed  eyes,  to  keep  his  balance — Romberg's 
symptom.  During  paroxysms  of  Meniere's  disease — aural  vertigo — the 
power  of  standing  in  the  erect  posture  is  wholly  lost.  Astasia  is  a  term 
employed  to  designate  inability  to  stand,  abasia  the  inability  to  walk,  in 
the  absence  of  paralysis.  Astasia-abasia  is  a  syndrome  of  hysteria  in 
which  the  patient  is  unable  to  stand  or  walk  but  can  usually  creep  about 
like  a  child,  upon  the  hands  and  knees. 

The  following  peculiarities  of  attitude  are  to  be  noted: 
In  hemiplegia  and  paralysis  of  one  leg  the  patient  supports  himself 
almost  entirely  upon  the  sound  leg.  In  chronic  sciatica  the  patient  spares 
the  affected  limb  both  in  walking  and  standing  by  fixation  of  the  hip-joint, 
and  in  doing  so  develops  a  scoliosis,  the  spinal  column  showing  a  double 
curvature,  the  lower  convex,  the  upper,  which  is  compensatory,  concave 
toward  the  affected  side,  the  general  inclination  of  the  body  being 
toward  the  sound  side.  In  paralysis  agitans  the  attitude  is  characteris- 
tic. The  head  and  upper  part  of  the  body  are  inclined  forward,  the  elbows 
and  knees  being  slightly  flexed.  The  striking  appearance  of  the  patient  is 
heightened  by  the  expressionless  countenance,  the  tremor,  and  the  move- 
ments of  the  fingers  and  hands.  In  pseudohypertrophic  paralysis  the 
patient  stands  with  his  feet  separated,  the  belly  protruding,  and  the 
shoulders  thrown  back  as  the  result  of  marked  lordosis.  In  the  sitting 
posture  the  curvature  of  the  spine  is  corrected. 


SYMPTOMS  AND  SIGNS:   GAIT.  433 


Gait. 


In  a  number  of  diseases,  especially  those  affecting  the  nervous  system, 
the  gait  is  much  modified  and  its  peculiarities  often  justify  conclusions 
regarding  both  functional  derangements  and  anatomical  lesions.  The 
following  symptomatic  gaits  are  frequently  observed: 

The  Paraplegic  Gait. — In  paresis  of  the  lower  extremities  the  gait 
is  feeble  and  uncertain.  Both  feet  are  slowly  advanced  and  dragged 
upon  the  floor.  The  patient  stumbles  over  trifling  inequalities  and  eleva- 
tions of  the  surface.  The  loss  of  power  is  frequently  more  marked  on  one 
side  than  on  the  other.  Crutches  become  necessary  and  at  length  the  loss 
of  power  is  complete.    This  gait  is  seen  in  chronic  myelitis. 

The  Hemiplegic  Gait. — When  the  hemiplegic  has  sufficiently  recov- 
ered to  walk,  the  gait  is  characteristic.  The  sound  limb  is  advanced, 
the  paralyzed  limb  dragged  after  it.  In  other  cases  the  step  of  the  para- 
lyzed limb  is  accomplished  by  lifting  the  pelvis  and  a  movement  of  cir- 
cumduction. When  contractures  have  taken  place  the  affected  arm  is 
rigid,  strongly  flexed  at  the  elbow  and  wrist  and  carried  across  the  body, 
and  the  fingers  and  thumb  are  flexed  upon  the  palm. 

The  Spastic  Gait.  —  In  spastic  paresis  of  the  lower  extremities 
such  as  occurs  in  forms  of  spinal  paralysis  there  is  peculiar  stiffness  of  the 
legs,  which  are  scarcely  bent  at  the  hip-  and  knee-joints,  while  the  thighs 
interfere  with  each  other  by  reason  of  the  contraction  of  the  adductors. 
The  contraction  of  the  gastrocnemii  produces  pes  equinus.  The  patient 
walks  with  two  canes  and  in  stepping  leans  upon  one,  lifting  the  pelvis  of 
the  opposite  side  as  he  steps,  and  dragging  the  foot  in  circumduction. 
In  some  cases  the  contact  of  the  foot  with  the  floor  produces  ankle  clonus 
which  adds  to  the  peculiarity  of  the  gait.  A  modification  of  the  spastic 
gait,  sometimes  seen  in  children,  is  known  as  cross-legged  progression. 
In  consequence  of  the  contraction  of  the  adductors  and  calf  muscles  there 
is  close  circumduction  of  the  knees,  and  in  stepping  the  legs  are  crossed 
and  the  advancing  foot  brought  down  not  only  in  front  of  but  to  the  out- 
side of  its  fellow. 

The  Steppage  Gait.  —  In  some  cases  of  peripheral  neuritis  the 
paralysis  of  the  extensors  of  the  feet  causes  a  peculiar  modification  in 
progression.  In  stepping  forward  the  knee  is  strongly  flexed  and  the  foot 
sharply  advanced  in  order  that  the  dragging  toes  may  be  lifted  from  the 
ground;  the  heel  is  brought  down  first  and  the  appearance  is  that  of  a  t 
person  stepping  over  obstructions. 

The  waddling  gait  occurs  in  pseudohypertrophic  muscular  paralysis 
and  is  not  less  characteristic  than  the  attitude  in  this  disease.  In  con- 
sequence of  the  lordosis  the  shoulders  are  thrust  back  and  the  belly 
forward,  the  legs  are  separated,  the  feet  raised  slowly  with  the  toes  drop- 
ping, the  centre  of  gravity  being  alt  ornately  shifted  over  the  foot  upon 
which  the  patient  throws  his  weight.  The  manner  in  which  the  child,  after 
lying  down  upon  the  floor,  gets  up  is  especially  characteristic.  He  rolls 
over  upon  the  abdomen,  gets  upon  all  fours,  and  first  extends  the  arms. 
then  the  legs.  The  hands  are  next  drawn  toward  the  legs  until  he  can 
grasp  one  knee  with  the  corresponding  hand.  He  pushes  himself  up  until 
28 


434  MEDICAL  DIAGNOSIS. 

the  other  knee  can  be  grasped  and  assumes  the  erect  posture  by  gradually 
raising  the  point  of  support  of  the  hand  upon  the  thigh.  Late  in  the  disease, 
when  the  atrophy  involves  the  muscles  of  the  upper  extremities,  it  becomes 
impossible  to  rise. 

The  ataxic  gait  is  that  of  incoordination  of  the  lower  extremities. 
It  is  observed  in  its  most  typical  form  in  tabes  dorsalis.  In  stepping  the 
foot  is  raised  higher  than  usual  with  a  jerk  and  rapidly  advanced  with 
an  awkward  and  irregular  movement,  the  toes  slightly  drooping.  It  is 
then  brought  down  with  an  abrupt  stamp  upon  the  heel  or  the  entire  sole. 
Progression  is  irregular  and  it  is  impossible  for  the  patient  to  walk  with 
one  foot  before  the  other,  as  in  following  a  crack  upon  the  floor  or  a  chalked 
line.  He  walks  with  a  swaying  motion.  The  legs  are  separated  in  order  to 
increase  the  base  of  support,  which  is  further  enlarged  as  the  disease  makes 
progress  by  the  use  first  of  one  cane,  later  of  two.  In  advanced  cases  walk- 
ing becomes  impossible  without  the  aid  of  one  or  even  two  attendants. 
Finally,  the  power  of  locomotion  is  entirely  lost.  These  symptoms  of  im- 
paired coordination  are  greatly  increased  upon  closing  the  eyes.  Patients 
who  can  go  about  fairly  well  in  daylight  cannot  walk  at  all  in  the  dark. 

The  gait  of  sciatica  derives  its  characteristics  from  muscular  fixation 
of  the  hip-joint  voluntarily  brought  about  to  diminish  pain. 

The  Gait  in  Chorea. — In  severe  chorea  the  irregular  muscular  con- 
tractions interfere  greatly  with  ordinary  movements.  The  gait  of  the 
patient  is  often  hopping  or  sliding,  sometimes  it  resembles  the  movements 
of  skating.     In  the  worst  cases  walking  becomes  impossible. 

The  reeling  or  staggering  gait  is  a  form  of  the  ataxic  gait.  It 
occurs  in  conditions  attended  with  marked  disturbance  of  coordination, 
such  as  drunkenness,  cerebellar  disease,  lesions  of  the  labyrinth,  and  some 
forms  of  paralysis  of  the  muscles  of  the  eye. 

The  Festinating  Gait. — This  modification  of  walking  occurs  in 
paralysis  agitans  and  is  not  less  characteristic  than  the  attitude  in  that 
disease.  The  patient  bends  forward,  the  elbows  are  slightly  abducted 
and  flexed,  the  knees  are  also  flexed,  and  the  patient  walks  with  the  appear- 
ance of  haste,  as  though  to  overtake  his  advancing  centre  of  gravity. 
He  cannot  halt  at  once.  The  peculiarity  of  the  gait  is  largely  due  to  stiff- 
ness and  weakness  of  the  muscles.  The  gait  is  sometimes  described  as 
propulsive.  A  similar  gait  and  inability  to  stop  immediately  sometimes 
shows  itself  in  exhausted  pedestrians.     Retropulsion  may  occur. 

Posture  and   Movements  of  Infants. 

The  position  and  movements  of  infants  are  of  diagnostic  impor- 
tance. The  healthy  baby  uses  its  muscles  and  joints.  Its  postures  are 
active,  its  movements  constant,  and  a  source  of  evident  pleasure.  It 
loves  to  be  fondled  and  played  with.  How  different  the  baby  who  is  realty 
ill!  Its  postures  are  passive.  Its  head  drops  and  rolls  from  side  to  side 
with  the  motion  of  the  pillow  upon  which  it  rests.  Its  limbs  dangle  help- 
lessly, and  voluntary  movements  are  slight  and  infrequent.  In  many 
febrile  diseases  there  is  cerebral  irritation,  shown  by  the  drawn  fcce  and 
head  pressure  deep  into  the  pillow.     In  severe  rickets  there  is  tenderness 


SYMPTOMS  AND  SIGNS:   TEMPERATURE.  435 

of  the  muscles  and  bones,  motion  is  painful  and  therefore  avoided;  in 
infantile  scurvy  a  similar  condition  exists,  and  in  well-developed  cases  the 
attitude  is  almost  diagnostic,  the  child  lying  upon  its  back  with  the  thighs 
and  legs  strongly  flexed,  shunning  all  movements  and  screaming  with 
fear  if  it  is  approached.  In  cerebrospinal  fever  and  other  forms  of  menin- 
gitis there  is  painful  retraction  of  the  muscles  of  the  back  of  the  neck — 
opisthotonos. 


IV. 

TEMPERATURE;    FEVER;    HYPOTHERMIA;    SIGNIFICANCE    OF 

ABNORMAL    TEMPERATURES. 

TEMPERATURE. 

Variations  in  the  temperature  of  the  body  constitute  symptoms  of 
great  importance  both  in  acute  and  in  chronic  disease.  From  the  earliest 
times  practitioners  estimated  the  heat  of  the  body  by  the  hand  and  thus 
sought  to  determine  the  presence  or  absence  of  fever.  The  introduction 
of  the  clinical  thermometer  into  medical  practice  marked  an  important 
advance  in  modern  medicine.     (See  Part  II,  Clinical  Thermometry.) 

Heat  Mechanism. — The  temperature  of  homothermous  or  warm- 
blooded animals  is  constant  within  narrow  limits  and  is  not  materially 
influenced  by  changes  in  the  temperature  of  the  medium  in  which  the 
organism  lives.  In  the  human  being  the  amount  of  heat  produced  and 
dissipated  at  different  parts  of  the  body  varies.  The  equilibrium  of  tem- 
perature is  maintained  in  part  by  direct  conduction  but  chiefly  by  the 
circulating  blood  and  lymph.  The  internal  parts  of  the  body  have  never- 
theless a  higher  temperature  than  the  external  and  some  internal  organs 
are  warmer  than  others.  The  heat  production  is  greater  in  organs  when 
they  are  active  than  when  they  are  at  rest,  and  the  temperature  varies  in 
different  regions  of  the  surface  of  the  body.  The  heat  mechanism  is  made 
up  of  two  factors:  (a)  heat  production  or  thermogenesis,  and  (b)  heat  dis- 
sipation or  thermolysis.  Under  normal  conditions  these  two  functions  so 
nearly  balance  that  the  mean  bodily  temperature  is  maintained  within 
very  narrow  limits.  The  regulating  mechanism  is  expressed  by  the  term 
thermotaxis.  It  is  obvious  that  thermotaxis  may  be  deranged  by  altera- 
tions in  either  thermogenesis  or  thermolysis. 

Thermogenesis  accompanies  oxidation.  Hence  almost  every  struc- 
ture of  the  body  may  be  regarded  as  the  source  of  heat.  In  this  respect 
the  skeletal  muscles  and  the  glands  play  the  chief  part.  The  general  ther- 
mogenic centres  have  been  shown  to  be  in  the  spinal  cord.  Thermogenic 
centres  probably  exist  in  the  caudate  nuclei,  pons,  and  medulla  oblongata; 
excitation  of  these  regions  is  followed  by  a  rise  in  heat  production — punc- 
ture pyrexia.  They  are  therefore  known  as  thermo-aocelerator  centres.  Irri- 
tation of  the  region  of  the  sulcus  cruciatua  and  at  the  junction  of  1  he  supra- 
Sylvian  and  post-Sylvian  fissures  in  the  dog  is  followed  by  a  decrease  in  heal 
production.     These  centres  are  therefore  known  as  thermo-inhibitory. 


436  MEDICAL  DIAGNOSIS. 

Thermolysis  or  heat  dissipation  is  the  result  of  radiation  and  conduc- 
tion from  the  surface,  of  the  evaporation  of  water  from  the  lungs  and  skin, 
and  of  the  warming  of  the  food,  drink,  and  inspired  air. 

Thermotaxis  or  heat  regulation  is  brought  about  by  reciprocal 
changes  in  heat  production  and  heat  dissipation  through  the  action  of 
cutaneous  impulses  and  of  variations  in  the  temperature  of  the  blood  upon 
the  thermogenic  and  thermolytic  centres.  Thus  in  an  animal  exposed  to 
moderate  cold,  heat  dissipation  is  increased,  but  cutaneous  impulses  are 
generated  which  excite  the  thermogenic  centres  and  heat  production  also 
is  increased,  whereas  an  increase  of  the  temperature  of  the  blood  increases 
the  activity  of  the  thermolytic  process.  In  either  case  the  temperature  of 
the  body  is  maintained.  Under  abnormal  conditions  this  reciprocal  influ- 
ence is  deranged. 

Abnormal  thermotaxis  is  a  term  used  to  designate  the  regulation  of 
the  heat  mechanism  under  pathological  conditions  in  which  the  body 
temperature  is  maintained  at  a  range  higher  or  lower  than  that  of  health. 

Under  ordinary  circumstances  the  presence  or  absence  of  hyperther- 
mia may  be  determined  by  the  hand,  but  this  mode  of  observation  yields 
no  accurate  data  either  for  comparison  or  record.  An  impression  as  to 
the  surface  temperature  is  thus  obtained  but  this  does  not  always  corre- 
spond with  the  internal  temperature  of  the  body.  During  a  chill  the  tem- 
perature of  the  skin,  in  consequence  of  the  contraction  of  the  arterioles,  is 
in  most  instances  greatly  reduced,  while  the  internal  temperature,  as  deter- 
mined by  the  thermometer,  is  high.  On  the  other  hand,  when  the  skin  is 
active  and  perspiring  and  evaporation  is  prevented  by  the  bed-clothing,  the 
surface  may  feel  hot  to  the  hand  while  the  internal  temperature  remains 
normal.  The  normal  axillary  temperature  ranges  about  98.6°  F. — 37°  C. 
It  undergoes  diurnal  oscillations  of  a  degree  to  a  degree  and  a  half,  falling 
to  97.5°-98°  F.  in  the  early  hours  of  the  morning  and  rising  to  99°-99.3°  F. 
toward  evening.  It  is  very,  probable  that  this  physiological  oscillation 
is  dependent  upon  the  alternations  of  sleep  and  waking.  Observations 
upon  men  who  have  habitually  slept  during  the  day  and  watched  during 
the  night  have  shown  an  inversion  of  the  curve.  A  slight  physiological 
rise  takes  place  during  gastric  digestion.  Violent  physical  exercise  is  fre- 
quently followed  by  a  temporary  rise  of  two  or  three  degrees;  this  fact 
may,  in  part  at  least,  explain  the  elevation  of  temperature  sometimes 
observed  after  a  violent  general  convulsion  and  which  is  very  common  in 
the  status  epilepticus.  In  children  and  adolescents  the  range  is  somewhat 
higher  than  in  adults  and  also  less  stable,  that  is  to  say,  the  diurnal  phys- 
iological oscillations  are  slightly  greater  and  the  sensitiveness  of  the  tem- 
perature to  pathogenic  influences  more  marked. 

Kieffer  states  that  careful  observation  has  shown  that  permanent 
increase  of  external  heat  in  the  tropics  is  followed  by  a  rise  of  bodily 
temperature  of  .05°  F.  for  every  degree  of  external  heat  above  the 
mean  annual  norm  and  that  as  a  direct  consequence  the  respiratory 
function  is  diminished,  the  pulse-frequency  slightly  decreased,  the  diges- 
tion, appetite,  and  assimilation  unfavorably  affected,  the  functional  activ- 
ity of  the  skin  greatly  increased,  and  the  nervous  system  distinctly 
depressed. 


SYMPTOMS  AND  SIGNS:    FEVER.  437 

In  aged  persons  the  diurnal  temperature  range  in  health  is  slightly 
lower  and  may  fall  to  97°  F.  (36.1°  C).  In  very  aged  persons,  on  the  other 
hand,  the  range  may  be  as  high  as  in  children. 

The  action  of  prolonged  or  intense  heat  and  cold  upon  the  temperature 
must  be  regarded  as  pathological. 

Abnormal  Temperature. — Variations  in  the  body  temperature  may  be 
plus  to  progressively  higher  ranges,  designated  subfebrile  and  febrile,  the 
latter  comprising  (a)  slight  fever,  (b)  moderate  fever,  (c)  high  fever,  (d) 
hyperpyrexia;  or  minus — subnormal  temperature  and  the  temperature  of 
collapse. 

The  term  pyrexia  is  used  to  designate  conditions  characterized  by 
elevation  of  temperature;  hyperpyrexia,  those  marked  by  excessively  high 
temperature;  and  apyrexia,  the  absence  of  fever.  Hypothermia  is  the 
term  applied  to  conditions  in  which  the  temperature  is  subnormal. 

FEVER. 

Elevation  of  temperature  alone  does  not  constitute  fever.  Extreme 
transient  rises  of  104°  F.  (40°  C.)  have  been  observed  after  violent,  pro- 
longed gymnastic  exercises,  and  much  higher  temperatures  in  hysteria, 
in  neither  case  associated  with  the  other  symptoms  which  enter  into  the 
modern  conception  of  fever.  These  symptoms  are,  in  addition  to  eleva- 
tion of  temperature,  subjective  sensations  of  illness,  cerebral  phenomena, 
weakness,  loss  of  appetite,  thirst,  increased  frequency  of  pulse  and  respi- 
ration, altered  urine,  and  derangements  in  nutrition  which  cause  wasting 
of  the  body.  It  is  furthermore  essential  to  our  conception  of  fever  and 
necessary  to  the  complete  manifestation  of  the  symptom-complex  that 
the  process  should  occupy  a  certain  time.  There  are,  however,  febrile 
periods  of  minimal  duration,  as  for  example  in  the  course  of  the  ague 
paroxysm,  in  which  most  of  the  objective  symptoms  occur  or  in  which,  if 
the  paroxysm  is  repeated  for  some  time  at  quotidian  or  tertian  intervals. 
all  of  them,  including  wasting  of  the  body,  are  manifest.  On  the  other  hand, 
the  acute  febrile  infectious  diseases  usually  run  a  self-limited  course,  meas- 
ured by  days  or  weeks;  again,  in  certain  of  the  chronic  infections,  as  forms 
of  tuberculosis,  there  may  be  fever  every  day  for  months.  Nor  are  these 
symptoms  altogether  dependent  upon  or  caused  by  the  elevation  of  tem- 
perature, as  is  shown  by  the  fact  that  artificial  over-heating  of  the  body 
produces  certain  of  them  but  not  all,  that  in  different  diseases  their  in- 
tensity by  no  means  corresponds  to  the  degree  of  the  temperature,  and 
that  marked  falls  of  temperature  can  occur  either  spontaneously  or  as  the 
result  of  antipyretic  treatment  without  a  corresponding  amelioration  in 
other  respects.  Flevation  of  temperature  is  nevertheless  a  constant  and 
essential  element  in  the  condition  known  as  fever  and  in  certain  cases 
dominates  the  clinical  picture.  In  a  majority  of  instances,  however,  the 
associated  conditions  constitute  a  much  more  important  measure  of  the 
gravity  of  the  case  than   the  range  of  temperature. 

Causes  of  Fever. — It  is  evident  thai  the  causes  of  fever  act  through 
the  nervous  system  and  thus  produce  derangements  of  the  heat-regulating 
function.     At  the  same  time  they  also  produce  derangements  of  the  normai 


438  MEDICAL  DIAGNOSIS. 

tissue  changes  with  increased  oxidation  and  heat  production.  They  con- 
sist of  soluble  toxic  substances  circulating  in  the  blood  and  are,  (a)  the 
result  of  infection  by  micro-organisms,  which  may  be  general  or  local,  or 
(b)  the  result  of  intoxication,  which  may  arise  within  the  body  itself  from 
faulty  metabolism  or  be  introduced  from  without,  as  in  food  poisoning. 
In  cases  of  infection  with  profound  nutritive  disturbances  toxins  derived 
from  both  these  sources  are  present.  In  either  event,  whether  the  fever- 
producing  agent  be  a  toxin  produced  by  the  growth  and  development  of 
micro-organisms  or  an  albumose,  ferment,  or  ptomaine  produced  by  faulty 
cell  metamorphosis  within  the  organs  or  tissues  themselves,  the  condition 
constitutes  a  toxaemia. 

Sapraemia  is  an  infection  of  the  blood  by  putrefactive  products. 

It  is  probable  that  in  the  rare  cases  of  fever  attributed  to  intense 
emotion,  as  fright,  or  to  violent  pain  or  peripheral  irritation,  the  rise  of 
temperature  is  caused  by  the  sudden  derangement  of  physiological  processes, 
with  the  production  of  toxins,  rather  than  by  direct  action  upon  the  heat- 
regulating  processes,  and  that  in  many,  though  not  all,  of  the  cases  of  cere- 
bral disease  accompanied  by  fever,  as  thrombosis,  hemorrhage,  and  tumor, 
the  elevation  of  temperature  is  due  to  local  infection  rather  than  to  implica- 
tion of  the  heat  centres,  while  the  symptom-complex  and  the  condition  of 
the  blood  in  sunstroke  render  it  highly  probable  that  the  elevation  of  tem- 
perature is  due  not  so  much  to  the  direct  effect  of  heat  upon  the  nervous 
system  as  to  toxic  substances  generated  by  the  action  of  heat  upon  the 
tissues  of  the  body  and  especially  upon  the  muscles.  It  is  thus  seen  that 
many  different  pathogenic  principles  developed  within  the  body  or  intro- 
duced from  without  are  directly  or  indirectly  capable  of  producing  the 
reaction  which  we  designate  by  the  term  fever. 

Symptoms  of  Fever. — These  substances  not  only  cause  elevation  of 
temperature  and  more  or  less  marked  disturbances  of  nutrition  but  they 
also  produce  subjective  sensations  of  illness  and  cerebral  symptoms,  such 
as  headache,  somnolence,  stupor,  and,  in  grave  cases,  coma  and  delirium, 
which  may  be  mild  and  wandering  or  active  and  maniacal.  Among  the 
effects  produced  upon  the  nervous  system  must  be  included  the  profound 
sensation  of  weakness  often  present  in  the  early  stages  of  febrile  diseases 
and  which  bears  no  direct , relation  to  the  inability  to  take  food  or  to  the 
wasting  of  the  tissues  of  the  body  which  occurs  later.  They  produce  de- 
rangements of  the  normal  secretions,  which  are  manifested  on  the  part  of 
the  skin  by  dryness  and  heat  or,  in  some  cases,  and  especially  at  the  time  of 
defervescence,  by  profuse,  even  colliquative  sweating,  on  the  part  of  the 
gastro-intestinal  tract  by  thirst,  loss  of  appetite,  dry,  furred  tongue,  im- 
paired digestion,  and  constipation,  and  on  the  part  of  the  urinary  appa- 
ratus by  scanty,  high-colored  urine  of  increased  specific  gravity. 

Pulse  in  Fever. — Derangement  of  the  pulse-frequency  is  a  constant 
phenomenon  of  fever.  To  what  extent  it  is  clue  to  elevation  of  the  tem- 
perature and  to  what  extent  to  the  action  of  fever-producing  toxins  upon 
the  nervous  system  cannot  be  determined.  In  almost  all  cases  of  fever 
there  is  an  acceleration  of  the  pulse-rate,  the  frequency  of  which  usually 
corresponds  to  the  intensity  of  the  fever.  Liebermeister  found  that  for 
every  degree  centigrade  (1.8°  F.)  of  elevation  of  temperature  above  ths 


SYMPTOMS  AND  SIGNS:   FEVER.  439 

normal  there  is  an  increase  of  eight  beats  of  the  pulse.  This  parallelism 
between  the  temperature  and  pulse  may  be  regarded  as  relatively  favor- 
able, whereas  a  greatly  increased  pulse-frequency  indicates  serious  caidiac 
or  vasomotor  disturbance  and  is  of  unfavorable  prognostic  significance. 
A  pulse-rate  of  140-160  in  the  adult  while  resting  quietly  in  bed  is  in  itself 
a  very  serious  symptom.  The  pulse-frequency  in  children  suffering  from 
febrile  diseases  is  relatively  high.  In  phthisis  with  moderate  fever  or  even 
in  the  absence  of  fever  there  is  commonly  a  quickened  pulse.  There  are 
cases  in  which,  notwithstanding  marked  elevation  of  temperature,  the  pulse- 
rate  remains  low.  This  departure  from  the  ordinary  parallelism  is  of 
diagnostic  importance.  High  temperatures  with  slow  pulse  are  observed 
in  cases  of  cerebral  disease  in  which  there  is  pressure  at  the  base,  as  tuber- 
culous meningitis,  in  yellow  fever,  and  in  febrile  diseases  in  individuals 
suffering  from  cardiac  lesions  attended  by  diminished  pulse- frequency,  as 
sclerosis  of  the  coronary  arteries  and  myocarditis.  It  is  to  some  extent 
characteristic  of  enteric  fever  that  the  pulse-frequency  is  moderate  as 
compared  with  the  elevation  of  temperature,  and  this  want  of  correspond- 
ence is  of  importance  in  the  differential  diagnosis  between  enteric  fever 
and  acute  miliary  tuberculosis  or  septicaemia,  in  both  of  which  the  pulse- 
rate  is  high. 

Respiration  in  Fever.  —  Increased  frequency  of  respiration  occurs  in 
almost  all  cases  of  fever.  That  this  phenomenon  is  in  part  due  to  the 
stimulating  effect  of  the  heated  blood  upon  the  respiratory  centre  has  been 
shown  experimentally;  exposure  to  artificial  heat  increases  the  frequency 
of  breathing.  That  it  is  also  in  part  due  to  the  direct  action  of  the  fever- 
producing  toxins  upon  the  respiratory  centre  is  rendered  probable  by  the 
/act  that  the  acceleration  of  breathing  bears  no  direct  ratio  to  the  elevation 
of  temperature  but  varies  greatly  at  the  same  temperature  in  different  dis 
eases.  It  is  a  matter  of  experience  that  cases  of  febrile  disease  in  which,  in 
the  absence  of  complications  on  the  part  of  the  respiratory  organs,  the  res- 
piration frequency  is  greatly  increased  are  almost  always  of  grave  import. 

Emaciation. — Wasting  accompanies  fever.  Even  in  febrile  attacks  of 
moderate  duration  the  loss  of  flesh  may  be  marked;  in  prolonged  fevers 
emaciation  may  be  extreme.  The  blood  undergoes  analogous  changes, 
the  patient  becomes  anaemic,  and  the  loss  of  flesh  at  the  close  of  a  prolonged 
fever  is  not  more  striking  than  the  pallor.  A  decrease  in  the  number  of  the 
erythrocytes  accompanies  all  cases  of  pyrexia,  but  requires  some  time  to 
become  manifest.    There  is  progressive  loss  of  the  albumins  of  the  plasma. 

Pyrexia  a  Symptom. — The  clinical  significance  of  fever  would  be  much 
less  important  were  it  not  for  the  fact  that  the  febrile  movement,  in  its 
mode  of  onset,  intensity,  course,  and  decline,  bears  a  relation  to  the  partic- 
ular morbid  condition  in  which  it  occurs,  frequently  definite  and  always 
suggestive. 

Until  recently  much  stress  was  laid  upon  the  distinction  between  symp- 
tomatic fever  and  essential  or  idiopathic  fever.  The  former  was  regarded 
as  a  manifestation  of  some  local  malady,  the  latter  as  constituting  the 
actual  disease.  The  stimulus  given  to  the  study  of  causes  by  the  science 
of  bacteriology  has  shown  that  this  distinction  is  more  apparent  than  real 
and  that  in  the  light  of  modern  pathology  pyrexia  is  always  a  symptom 


440  MEDICAL  DIAGNOSIS. 

Idiopathic  Fever. — Nevertheless  there  is  a  group  of  acute  infectious 
diseases  in  which  fever  is  not  only  constantly  present  but  also  the  most 
conspicuous  symptom,  and  in  which  the  morbid  process  is  literally  coex- 
tensive with  the  febrile  movement,  which  is  self-limited,  the  illness  begin- 
ning with  the  rise  of  temperature  and  the  convalescence  setting  in  with 
defervescence.  This  group  constitutes  the  idiopathic  fevers  or,  more 
simply,  the  fevers. 

Varieties. — Subdivisions,  arranged  according  to  the  course  of  the 
febrile  movement,  are  (a)  the  continued  fevers,  as  influenza  and  enteric 
fever,  and  (b)  the  periodical  (malarial)  fevers,  as  intermittent,  remittent, 
and  pernicious  fever.  In  some  of  the  continued  fevers  other  symptoms, 
as  eruptions,  are  no  less  constant  or  characteristic  than  the  course  of  the 
fever, — a  fact  which  led  to  the  establishment  of  a  further  subdivision 
upon  an  entirely  different  basis  of  classification,  which  comprises  the 
exanthemata  or  the  eruptive  fevers.  Furthermore,  in  certain  of  the 
diseases  which  are  regarded  as  continued  fevers,  a  characteristic  periodicity 
occurs,  or  the  course  of  the  disease  is  interrupted  by  periods  of  apyrexia  of 
considerable  duration,  an  example  of  which  is  relapsing  fever,  whereas  in 
the  periodical  fevers,  strictly  so-called,  namely,  the  malarial  infections, 
there  are  certain  cases  in  which  the  febrile  movement  lacks  distinct  peri- 
odicity— continued  malarial  fever — or  is  absent  altogether — malarial 
infection  without  fever.  On  the  other  hand  there  is  a  large  group  of  diseases 
that  has  nothing  to  do  with  malaria  in  which  the  occurrence  of  febrile 
paroxysms,  separated  by  very  definite  periods  of  apyrexia,  in  other  words, 
distinct  periodicity,  is  characteristic — for  example,  the  hectic  fever  of 
pulmonary  tuberculosis,  hepatic  fever,  urethral  fever,  and  the  fever  in  some 
cases  of  malignant  endocarditis.  Finally,  there  are  local  and  general  in- 
fections in  which  the  symptom  fever  is  inconstant  and  irregular.  For  these 
and  other  reasons,  the  principal  of  which  is  that  fever  is  always  sympto- 
matic and  never  of  itself  an  actual  disease,  the  distinction  between  symp- 
tomatic fever  and  essential  or  idiopathic  fever  has  been  abandoned — a  long 
step  in  the  direction  of  a  scientific  or  etiological  basis  for  the  classification 
of  diseases.  Terms  and  phrases  that  have  long  lost  their  original  significance 
remain  to  encumber  the  literature  and  embarrass  the  study  of  medicine 
and  the  period  is  remote  when  we  shall  cease  to  speak  of  scarlet  fever  or 
yellow  fever. 

Type  in  Fever. — Type  is  a  term  loosely  used  to  indicate  the  intensity 
of  fever.  Thus  we  speak  of  fever  of  mild  type  or  fever  of  grave  type.  It  is 
applied  more  accurately  to  the  course  or  range  of  the  temperature  as  de- 
picted upon  clinical  charts.  There  are  three  principal  types  of  fever:  (a) 
the  continued,  in  which  the  limits  of  the  diurnal  range  do  not  usually 
exceed  1.8°  F.  (1°  C),  the  fall  occurring  in  the  morning,  the  rise  in  the 
evening.  This  is  about  the  measure  of  the  diurnal  oscillation  in  health. 
There  is,  therefore,  a  parallelism  between  the  temperature  of  health  and 
fever  of  the  continued  type,  the  latter  being  elevated  two  or  more  degrees 
above  the  former  and  fluctuating  in  harmony  with  it.  Since  the  tempera- 
ture range  upon  the  chart  is  represented  not  by  a  straight  but  by  a  curved 
line  showing  the  diurnal  oscillations  it  is  better  to  describe  this  as  the 
subcontinuous  type.    Fever  of  this  type  is  characteristic  of  the  f  astigiuro 


SYMPTOMS  AND  SIGNS:    FEVER. 


4*1 


of  uncomplicated  enteric  fever,  (b)  The  remittent  type,  characterized  by 
falls  of  several  degrees  in  the  temperature,  which  does  not,  however,  reach 
the  normal.  The  remissions  may  take  place  at  any  hour  of  the  day  and  are 
often  accompanied  by  free  sweating.  They  are  followed  in  the  course  of  a 
few  hours  by  exacerbations  of  greater  or  less  extent.  There  is  no  parallelism 
between  fever  of  this  type  and  the  normal  temperature  range.  This  is  the 
type  seen  in  some  forms  of  estivo-autumnal  malaria  and  in  septic  condi- 
tions,    (c)  The  intermittent  type,  characterized  by  a  fall  of  temperature 


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fever. 


enteric       Fig.  183. — Intermittent  malari 
single  tertian  infection.   Man 


al  fever,  tertian  type; 
,  aged  thirty-three. 


from  febrile  ranges  to  the  normal  or  below  it,  a  period  of  apyrexia  of  vari- 
able duration,  and  the  recurrence  of  fever.  The  febrile  paroxysms  are  of 
short  duration  as  compared  with  the  intermission  and  commonly  begin 
with  a  chill  and  terminate  in  profuse  sweating.  During  the  intermission 
the  patient  usually  feels  fairly  comfortable  or  quite  well.  Fever  of  this 
type  occurs  in  malaria.  The  repetition  of  the  paroxysms  may  extend 
over  a  considerable  time.  Intermittent  fever  in  which  the  paroxysm  recurs 
daily  is  known  as  (/not  id  ian;  when  the  paroxysm  recurs  upon  the  third 
day,  including  the  day  of  onset,  it  is  tertian;  when  it  recurs  upon  the  fourth 
day,  quartan.  The  paroxysms  may  occur  at  any  period  of  the  day  and 
usually  at  the  same  hour.  In  malaria  they  ordinarily  recur  in  the  fore- 
noon, in  hectic  fever  in  the  afternoon,    (d)  The  inverse  type.     The  tern- 


442 


MEDICAL  DIAGNOSIS. 


perature  in  fever  of  the  continued  type  and  in  many  cases  of  the  remit- 
tent type  undergoes  diurnal  oscillations  of  wider  excursus  than  those  of 
health  but  corresponding  to  them  in  time.  That  is,  the  remission  occurs 
in  the  early  morning  hours,  the  exacerbation  toward  evening.  In  excep- 
tional cases  the  remission  takes  place  in  the  evening  and  the  exacerbation 
in  the  morning — inverse  type.  Fever  of  this  type  occasionally  occurs  in 
tuberculosis  and  in  rare  instances  in  enteric  fever. 


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Fio.  184. — Intermittent  malarial  fever,  quotidian  type; 
double  tertian  infection.     Man,  aged  twenty-nine. 


Fig.  185. — Temperature  of  inverse  type. 


Atypical  Fever. — In  many  febrile  diseases  the  temperature  range  is 
altogether  irregular.  This  is  especially  the  case  in  diseases  in  which  the 
symptoms  in  general  are  irregular  or  atypical,  as  diphtheria  and  the  va- 
rious septic  infections. 

The  Type  of  Fever  in  Particular  Diseases. — Many  of  the  febrile  infec- 
tions have  a  characteristic  temperature  range.  The  febrile  movement  in 
uncomplicated  cases  on  the  one  hand  is  self-limited  and  on  the  other  under- 
goes definite  modifications  at  different  stages  in  the  course  of  the  affection 
and  upon  the  occurrence  of  special  manifestations,  as  the  appearance  of  an 
eruption.  In  a  more  narrow  sense  the  temperature  range  in  such  diseases 
is  said  to  be  typical  or  to  conform  to  type.  It  is  to  be  borne  in  mind, 
however,  that  marked  departures  from  type  may  occur  in  consequence  of 
variations  in  the  intensity  of  the  infection,  peculiarities  on  the  part  of  the 


SYMPTOMS  AND  SIGNS:    FEVER. 


443 


individual,  the  occurrence  of  complications,  and  from  the  action  of  drugs. 
The  type  of  fever,  both  as  regards  the  daily  range  and  the  temperature 
curve  throughout  the  course  of  the  attack,  constitutes  a  valuable  aid  to  diag- 
nosis, and  is  always  to  be  taken  into  consideration.  It  is  rarely  possible, 
however,  to  make  a  diagnosis  from  the  temperature  alone,  nor  is  it  desirable. 
In  connection  with  the  temperature  we  must  consider  the  other  symptoms 
and  signs,  the  surrounding  circumstances,   and  the   previous  treatment. 

In  well-developed  cases,  unmodified  by 
complication  or  treatment,  the  temperature 
curve  may  be  said  to  be  characteristic  in 
the  following  diseases:  tertian  and  quartan 
malaria,  enteric  fever,  typhus  fever,  relaps- 
ing fever,  and  croupous  pneumonia.  It  con- 
forms in  a  general  way  to  type,  but  less 
closely,  in  scarlatina,  measles,  erysipelas,  and 
the  variolous  diseases.  It  is  variable  and 
atypical  in  cerebrospinal  fever,  rheumatic 
fever,  endocarditis,  and  the  septic  infections. 

Stages. — The  course  of  the  attack  may 
be  divided  into  (a)  the  stage  of  prodromes, 
(b)  the  onset  or  stage  of  invasion,  (c)  the 
fastigium,  and  (d)  the  defervescence  or  stage 
of  decline.  In  typical  cases  of  the  different 
febrile  diseases  each  of  these  periods  has  a 
definite  duration  and  a  characteristic  curve 
upon  the  temperature  chart. 

(a)  The  Stage  of  Prodromes.  —  This  pe- 
riod is  usually  marked  by  vague  feelings  of 
discomfort,  lassitude,  pain  in  the  back,  un- 
sound sleep,  and  feverishness,  the  tempera- 
ture reaching  subfebrile  or  even  mild  febrile 
elevations  in  the  later  part  of  the  day.  These 
symptoms  are  often  absent.  Prodromes  usu- 
ally occur  in  diseases  of  gradual  develop- 
ment.    They  are  common  in  enteric  fever. 

(b)  The  Onset  or  Stage  of  Invasion. — The  rise  of  temperature  may  be 
gradual  or  abrupt.  When  gradual  the  evening  exacerbations  exceed  the 
morning  remissions  in  such  a  way  that  the  temperature  rises  progressively 
to  the  fastigium  or  acme.  Under  these  circumstances  the  stage  of  invasion 
may  occupy  a  period  of  several  days,  as  in  enteric  fever.  When  abrupt  the 
acme  is  reached  at  once  or  in  the  course  of  a  few  hours,  as  in  scarlet  fever, 
influenza,  or  croupous  pneumonia.  The  onset  is  very  often  attended  by 
chilliness  or  a  chill.  This  symptom  may  vary  in  intensity  from  transient 
sensations  of  cold,  with  shivering,  pallor,  and  slight  cyanosis  of  the  lips  and 
finger-tips,  to  a  severe  and  prolonged  chill  or  rigor,  with  violent  shaking  or 
tremor  of  the  whole  body,  chattering  teeth,  cold  extremities,  and  marked 
cyanosis.  The  temperat  lire  of  t  he  surface  of  the  body  is  much  reduced  and 
the  patient  experiences  a  sensation  of  extreme  cold,  whereas  the  internal 
temperature,  taken  in  the  rectum,  is  high,  101°- 107°  F.  (40°-42°  C).    The 


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444 


MEDICAL  DIAGNOSIS. 


violence  of  the  chill  commonly  corresponds  with  the  abruptness  of  the  onset. 
The  insidious  and  gradual  invasion  of  enteric  fever  is  not  often  attended  by 
chills.  The  abrupt  onset  of  croupous  pneumonia  very  frequently  manifests 
itself  by  a  prolonged  chill  of  great  severity,  occurring  without  warning  in 
a  condition  of  apparent  health.  The  chill  which  ushers  in  the  febrile  par- 
oxysm or  ague  fit  of  malaria  is  intense  and  prolonged,  and  the  congestive 
chill  of  the  algid  variety  of  pernicious  estivo-autumnal  malaria  may  termi- 
nate in  death.  Chills  occurring  later  in  the  attack  may  mark  the  develop- 
ment of  an  intercurrent  disease,  as  croupous  pneumonia  in  the  course  of 
enteric  fever.  The  chills  of  malignant  endocarditis  cannot  be  distinguished 
from  the  ague  paroxysm,  the  resemblance  to  which  is  frequently  heightened 
by  a  regular  periodicity.  Ague-like  chills  occur  in  some  cases  of  phthisis 
and  are  common  in  local  suppurations  with  pent-up  pus,  cholelithiasis,  and 
septic  and  other  conditions  attended  by  fever  of  intermittent  type. 


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The  perturbation  of  the  nervous  system,  which  is  manifested  in  the 
adult  as  a  chill,  may  show  itself  in  the  child  as  a  convulsion,  sudden  stupor, 
or  very  rarely  as  an  outbreak  of  delirium.  In  the  adult  the  onset  of  an 
acute  febrile  infection  may  be  marked  by  sudden  maniacal  delirium  and 
patients  developing  pneumonia  or  enteric  fever  have  in  some  instances 
been  regarded  as  insane  and  committed  to  an  asylum. 

The  chill  which  attends  the  general  or  local  infections  and  which  is  of 
varying  intensity  must  be  distinguished  from  the  so-called  nervous  chill 
which  sometimes  occurs  in  persons  of  neurotic  constitution  under  condi- 
tions of  excitement,  intense  pain,  moderate  shock,  or  great  fatigue.  Under 
such  circumstances  there  may  be  trembling  and  agitation,  but  the  pulse 
remains  good,  the  normal  color  is  preserved,  and  the  thermometer  does  not 
show  a  rise  in  temperature. 

(c)  The  Fastigium  or  Acme. — Fastigium  is  literally  the  summit  or 
ridge  of  a  building.  The  temperature  range  in  the  continued  fevers  shows 
diurnal  remissions  and  exacerbations  corresponding  to  those  of  health,  but 
somewhat  greater.     The  elevation  above  the  normal  differs  in  different 


SYMPTOMS  AND  SIGNS:    FEVER. 


445 


diseases  and  in  different  cases  of  the  same  disease.  In  croupous  pneumonia 
and  in  typhus  and  relapsing  fevers  the  elevation  is  high.  In  many  cases  of 
enteric  fever  it  is  moderate.  A  parallelism  with  the  temperature  of  health 
is  to  some  extent  maintained  in  the  continued  fevers.  This  parallelism 
may,  however,  be  interrupted  by  accidents,  as  hemorrhage  or  perforation 
in  enteric  fever,  complications,  as  empyema  in  pneumonia,  the  occurrence 
of  pseudocrises,  the  action  of  antipyretic  drugs,  or  the  external  applica- 
tion of  cold  by  means  of  baths  or  otherwise.     In  the  periodical  fevers  the 


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years  old.     Defervescence  by  crisis  on  the  evening 
of  the  sixth  day. 


-Pneumonia.    Early  defervescence;  inter- 
rupted crisis. 


diurnal  range  is  much  greater  than  in  health.  The  term  acme  is  used  to 
indicate  the  summit  of  the  range  when  the  febrile  movement  is  transient, 
as  in  influenza  or  the  ague  paroxysm. 

An  abundant  hemorrhage  from  any  surface,  especially  intestinal  hem- 
orrhage in  enteric  fever,  causes  an  abrupt  fall  of  the  temperature  to  normal 
or  below  it.  The  shock  of  perforation  is  likewise  accompanied  by  a  fall  of 
several  degrees. 

A  normal  temperature  In  the  course  of  fever  may  thus  assume  the 
significance  of  an  abnormal  temperature. 

In  abortive  cases  of  enteric  fever,  especially  in  children,  the  defer- 
vescence is  often  critical.  Intercurrent  diseases  and  complications  may 
cause  a  rise  above  the  range  of  the  fastigium. 


446 


MEDICAL  DIAGNOSIS. 


c. 

r-42 


(d)  The  Defervescence  or  Stage  of  Decline. — The  fall  of  temperature 
may  be  abrupt,  or  gradual.  The  former  is  known  as  crisis  or  critical  defer- 
vescence, the  latter  as  lysis.  The  abrupt  fall  in  crisis  amounts  to  several 
degrees  in  the  course  of  a  few  hours.  The  temperature  usually  reaches 
subnormal  ranges  from  which  it  reacts  gradually.  The  fall  may  be  broken 
by  a  slight  rise — interrupted  crisis.  It  is  often  attended  by  critical  dis- 
charges, such  as  copious  perspiration,  passage  of  a  large  quantity  of  urine, 
or  large  liquid  stools.  Not  infrequently  it  occurs  during,  or  is  followed  by, 
a  deep  and  prolonged  sleep  from  which  the  patient  awakes  refreshed  but 

weak  and  exhausted.  There  is  a  corre- 
sponding fall  in  the  pulse  and  respiration 
frequency.  The  gradual  fall  in  lysis  takes 
place  by  progressive  increase  in  the  morn- 
ing remissions  and  decrease  in  the  evening 
exacerbations  until  normal  or  subnormal 
ranges  are  attained.  This  process  fre- 
quently extends  over  several  days,  as  in 
enteric  fever.  The  term  rapid  lysis  is  ap- 
plied to  a  gradual  defervescence  of  shorter 
duration.  Febrile  diseases  of  sudden  onset, 
such  as  croupous  pneumonia,  for  instance, 
not  infrequently  terminate  by  crisis,  while 
those  of  gradual  invasion  commonly  ter- 
minate in  lysis. 

Persistence  of  fever  beyond  the  normal 
period  in  a  self-limited  disease  is  due  usu- 
ally to  a  complication;  sometimes  to  re- 
lapse. The  febrile  course  of  measles  is  fre- 
quently prolonged  by  bronchopneumonia; 
of  scarlet  fever  by  middle-ear  disease, 
endo-  or  pericarditis,  pleurisy,  or  nephritis; 
of  enteric  fever  by  phlebitis,  abscess  forma- 
tion, cholecystitis,  necrosis  of  cartilage  or 
bone,  some  form  of  secondary  infection,  or 
by  relapse.  Cases  of  enteric  fever  extend- 
ing to  the  fifth  week  or  longer,  in  which 
no  complication  can  be  discovered,  are 
mostly  instances  of  intercurrent  relapse. 

The  Temperature  during  Convalescence. — In  the  early  days  of  con- 
valescence from  acute  febrile  disease  the  temperature  range  is  frequently 
subnormal.  It  is  also  labile,  that  is  to  say,  very  readily  disturbed  by 
trifling  influences,  such  as  constipation,  the  return  to  solid  food,  mental 
excitement,  or  over-exertion.  A  transient  rise  of  temperature  produced  by 
any  of  these  causes  is  known  as  a  recrudescence. 

Relapse. — A  recurrence  of  fever,  together  with  the  characteristic 
symptoms  of  the  primary  attack,  due  to  reinfection.  Instances  of  two  or 
more  relapses — multiple  relapse — are  of  occasional  occurrence.  That  form 
of  relapse  which  begins  before  the  defervescence  from  the  primary  attack 
is  completed  is  known  as  intercurrent  relapse. 


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SYMPTOMS  AND  SIGNS:   FEVER. 


447 


Bed  Fever. — Patients  who  have  passed  through  febrile  diseases  some- 
times develop  during  convalescence  a  moderate  febrile  movement,  .the 
evening  exacerbations  ranging  as  high  as  100°  or  101°  F.  This  fever  tends 
to  run  on  indefinitely  but  may  quickly  disappear  if  the  patient  is  allowed 
to  sit  up.  A  diagnosis  of  bed  fever  should  never  be  made  until  other  fever- 
producing  conditions  are  excluded. 

Paroxysmal  Fever. — The  fever  recurs  at  intervals.  The  temperature 
is  high  and  the  accompanying  symptoms  usually  severe.  The  febrile  move- 
ment is  of  short  duration  and  commonly  preceded  by  a  chill  and  followed 
by  profuse  sweating. 


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Periodical  Fever. — The  periodicity  may  be  regular  or  irregular. 
Intermittent  and  remittent  fevers  are  periodical.  Tertian  and  quartan 
malaria  constitute  the  very  type  of  the  regularly  recurring  periodical 
fevers.  The  periodicity  of  the  estivo-autumnal  fevers  is  not  so  well  de- 
fined; the  type  is  blurred  and  in  some  cases  wholly  obliterated.  \\  e 
observe  forms  of  continued  malarial  fever  due  to  estivo-autumnal  infection. 

Other  febrile  diseases  are  characterized  by  periodicity — a  matter  of 
greal  practical  importance  in  diagnosis. 

Paroxysmal  fever,  often  of  regular  periodicity,  may  occur  in  the 
following  conditions:     (a)   Abscess  formation  and  other  suppurative  proc- 

-,  as  empyema.  In  cerebral  abscess  the  temperature  may  be  continu- 
ously normal  or  subnormal.     Evacuation  of  pus  and  free  drainage  is  fol- 


448 


MEDICAL  DIAGNOSIS. 


lowed  by  disappearance  of  fever,  (b)  Pyaemia  and  septicaemia,  (c)  Malig- 
nant endocarditis,  (d)  Suppurative  and  infectious  processes  in  the  liver 
and  bile-passages — hepatic  fever.  Under  this  heading  are  abscess  cf  the 
liver,  diffuse  cholangitis,  cholecystitis,  inflammation  of  the  hepatic,  cystic, 
and  common  ducts,  gall-stone  disease,  especially  impacted  gall-stones,  and 
hypertrophic  cirrhosis,  (e)  Infections  of  the  genito-urinary  tract,  as  cysti- 
tis and  pyelitis,  prostatic  abscess,  and  after  the  passage  of  the  catheter  or 
sound — catheter  fever,  urinary  fever,  (f)  Tuberculosis.  Paroxysmal  fever 
is  present  in  the  acute  miliary  form,    the  early  stages  of  many  cases  and 


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Fig.  192. — Urethral  fever.   Man,  aged  sixty-four. 


Fig.  193. — Cerebral  hemorrhage.   Hyperpyrexia. 
Pre-agonistic  rise  of  temperature. 


the  later  stages — after  cavity  formation — of  almost  all  cases  of  pulmonary 
phthisis,  and  very  often  in  acute  tuberculous  processes  involving  the  bones, 
joints,  and  glands.  Sometimes  in  the  last  few  days  of  consumption  the 
fever  wholly  ceases,  (g)  Hodgkin's  disease  and  leukaemia.  Periods  of 
fever  may  be  separated  by  prolonged  periods  of  apyrexia.  (h)  Syphilis. 
The  initial  fever  may  come  on  within  four  or  six  weeks  after  infection  and 
persist  for  several  weeks.  Paroxysmal  fever  in  some  instances  accom- 
panies the  development  of  gummata  and  other  lesions  of  the  tertiary 
period,  (i)  Rapidly  growing  malignant  neoplasms,  (j)  Very  rarely  in 
morphinism,  the  febrile  paroxysm  being  preceded  by  a  chill  and  followed 
by  copious  sweating.  If  the  minimal  temperatures  fall  to  or  below  the 
normal  the  fever  is  intermittent  in  type;   if  they  fail  to  reach  the  normal 


SYMPTOMS  AXD  SIGNS:  HYPOTHERMIA.  449 

it  is  of  remittent  type.  In  the  course  of  any  of  the  foregoing  diseases  the 
fever  may  change  from  one  to  the  other  of  these  types  and  frequently 
it  becomes  irregular  and  wholly  atypical.  In  the  course  of  defervescence  by 
lysis  as  the  fever  gradually  falls  to  normal  it  passes  from  the  subcontinu- 
ous  type  of  the  fastigium  first  to  the  remittent  type,  then  to  intermittent. 

The  febrile  paroxysms,  in  some  cases  of  pyaemia,  malignant  endo- 
carditis, and  tuberculosis,  and  of  disease  of  the  liver  and  bile-passages,  are 
ushered  in  by  rigor  and  terminate  by  sweating,  and  recur  with  such  regu- 
larity that  they  closely  resemble  the  ague  paroxysms  of  malaria.  Errors 
of  diagnosis  are  common,  but  readily  avoided  by  close  observation,  exam- 
ination of  the  blood,  and  the  therapeutic  test  of  quinine. 

Hyperpyrexia. — Excessively  high  temperatures  are  occasionally  ob- 
served. The  thermometer  may  register  105.8°  F.  (41°  C.)  and  higher  in 
injuries  involving  the  cervical  portion  of  the  spinal  cord,  and  in  tetanus, 
rheumatic  fever,  scarlet  fever,  enteric  fever,  yellow  fever,  and  sunstroke. 
Very  high  temperatures  occur  in  croupous  pneumonia,  the  paroxysms  of 
malarial  fever,  relapsing  fever,  and  erysipelas.  A  marked  rise  may  occur 
in  the  acute  infections  just  before  death — pre-agonistic  rise.  Excessive 
temperature  when  transient  is  not  necessarily  of  grave  prognostic  import; 
if  continued  for  some  hours  it  is  apt  to  be  followed  by  death.  Da  Costa 
has  recorded  a  temperature  of  110°  F.  (43.3°  C.)  in  a  case  of  cerebral  rheu- 
matism, Jacobi  has  seen  in  scarlet  fever  107.6°  F.  (42°  C),  Sahli  113°  F. 
(45°  C.)  in  enteric  fever,  Richet  107°  F.  (41.7°  C.)  in  sunstroke,  with  re- 
covery. The  literature  contains  many  instances  of  recovery  after  such 
temperatures.  There  are  well  authenticated  cases  of  even' higher  temper- 
atures with  recovery.  The  most  remarkable  is  that  of  Teale,  reported  to 
the  London  Clinical  Society  in  1875.  A  lady  fell  from  her  horse  and  sus- 
tained serious  spinal  injuries.  For  sixty  days  she  had  frequent  rises  of 
temperature  to  111.2°  F.  (44°  C.)  and  higher  but  eventually  recovered. 
Bryant,  Guy's  Hospital  Reports;  1894,  has  recorded  the  facts  of  one  hun- 
dred cases  of  hyperpyrexia,  several  of  which,  however,  are  not  above 
suspicion.  Many  of  the  cases  of  excessively  high  temperature  have  oc- 
curred in  hysterical  persons  and  several  of  the  most  remarkable  instances 
on  record  are  obviously  the  result  of  deception. 

HYPOTHERMIA. 

Subnormal  Temperature. — Hypothermia  may  be  present  under  the 
following  conditions: 

(a)  The  intense  action  of  external  cold.  A  transient  body  tempera- 
ture of  86°  F.   (30°  C.)   may  occur,  yet  recovery  take  place. 

(b)  After  a  pronounced  crisis  at  the  close  of  an  acute  infectious  dis- 
ease, as  pneumonia.  Postcritical  falls  to  95°  F.  (35°  C.)  or  even  to  93.2°  F. 
(34°  C.)  have  been  observed. 

(c)  In  shock  and  collapse.  The  fall  of  temperature  is  associated  with 
signs  of  failure  of  the  circulation,  frequent,  small,  or  imperceptible  pulse, 
colliquative  sweating,  great  relaxation,  and  extreme  pallor.  The  mind, 
except  in  the  presence  of  cerebral  lesions,  usually  remains  clear.  The  con- 
dition may  be  transient  or  it  may  be  the  immediate  forerunner  of  death. 

29 


450 


MEDICAL  DIAGNOSIS. 


Subnormal  temperature  may  be  the  result  of  internal  or  external  hemor- 
rhage, traumatism,  surgical  operation,  prolonged  anaesthesia,  the  apoplectic 
insult  in  cerebral  hemorrhage,  embolism  or  thrombosis,  the  sudden  rupture 
of  a  hollow  viscus  with  the  discharge  of  its  contents  into  the  peritoneum, 
or  finally  the  action  of  intense  pain  or  a  sudden,  overwhelming,  depressing 
emotion  in  a  neurotic  individual.  When  reaction  takes  place  the  tempera- 
ture rises  very  often  to  febrile  ranges,  either  as  the  result  of  infection  or,  in  the 
case  of  cerebral  or  spinal  lesions,  from  irritation  of  the  tissues  which  constitute 


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Fig.  195. — Enteric  fever;  subnormal  temperature 
due  to  repeated  hemorrhage. 


the  heat  centres.  In  lesions  of  the  cerebrospinal  axis  the  reactive  fever  is 
frequently  due  to  inflammatory  reaction  in  the  neighborhood  of  the  lesion. 

(d)  In  various  conditions  attended  by  greatly  diminished  tissue 
change  or  profound  disturbance  of  the  heat  mechanism,  as  in  the  coma 
attending  acute  poisoning  from  alcohol,  illuminating  gas,  carbolic  acid,  and 
other  toxic  agents,  starvation,  carcinoma  of  the  oesophagus,  other  internal 
cancers,  abscess  of  the  brain,  myxcedema,  sclerema  neonatorum,  and  in  some 
forms  of  mental  disease,  as  melancholia.  Subnormal  temperature  ranges 
are  also  occasionally  observed  in  profound  anaemia,  the  terminal  stages  of 
tuberculous  processes,  especially  tuberculous  peritonitis,  and  in  diabetes. 

The  Action  of  Drugs  upon  the  Temperature. — Antipyretic  drugs, 
most  of  which  are  synthetic  products  of  coal-tar,  while  capable  of  produc- 


SYMPTOMS  AND  SIGNS:    ABNORMAL  TEMPERATURES.    451 


c. 

_42» 


ing  marked  effects  upon  febrile  temperatures,  have  little  influence  upon  the 
body  temperature  in  health.  Their  free  use  in  fever  is  followed  by  a  tend- 
ency to  collapse,  and  the  resulting  fall  of  temperature  is  of  short  duration. 

External  Antipyretics. — Cold  baths  or  gradually  cooled  baths,  spong- 
ing, packs,  ice-bags,  circulating  coils  for  the  application  of  iced  water,  and 
cold  enemata  reduce  the  febrile  temperature  not  only  without  the  pertur- 
bating  effects  of  drugs  but,  if  rightly  employed,  with  a  favorable  influence 
upon  the  general  condition  of  the  patient. 

Trifling  rises  of  temperature  follow  the  administration  of  full  doses 
of  atropine,  cocaine,  strychnine,  caffeine,  and  certain  other  drugs,  while 
correspondingly  slight  falls  occur  after  morphine,  quinine,  alcohol,  and  the 
general  anaesthetics. 

THE  SIGNIFICANCE  OF  ABNORMAL 

TEMPERATURES. 

• 

To  recapitulate:  A  rise  of  temperature,  if  moderate,  may  be  physio- 
logical— digestion,  violent  muscular  effort.  Such  rises  are  commonly  tran- 
sient. If  the  rise  be  accompanied  by  other 
symptoms  of  fever  it  may  indicate  (a)  an 
infection,  either  general  or  local;  (b)  an  in- 
toxication, which  may  arise  within  the  body 
from  faulty  metabolism  or  be  introduced 
from  outside  the  body,  as  in  the  case  of  food 
or  drink;  (c)  a  lesion  involving  the  heat- 
regulating  mechanism  of  the  nervous  system. 

As  a  rule  there  are  associated  sj^mp- 
toms  which  render  practicable  the  differen- 
tial diagnosis  of  these  conditions. 

A  fall  of  temperature  may  indicate 
blood  loss,  which  may  be  internal  and  con- 
cealed, as  in  a  small  rupture  of  the  wall  of 
the  heart  not  presently  fatal;  a  similar  leak- 
age from  an  aneurism;  collapse,  as  in  apo- 
plexy; excessive  radiation,  as  in  exposure; 
diminished  metabolism,  as  in  convalescence, 
starvation,  forms  of  poisoning,  and  certain 
nutritional  and  nervous  diseases.  The  fall 
may  be  transient  or  sustained. 

Whether  the  temperature  be  higher  or 
lower  than  the  normal  it  serves  to  exclude 
malingering  and,  as  a  rule,  hysteria.  It  is 
important  to  bear  in  mind  that  remarkable 
departures  from  the  normal  temperature  are 
observed  in  some  cases  of  hysteria,  and  that 
the  clever  malingerer  often  plays  tricks  with 
the  thermometer  that  arc  as  difficult  of  detection  as  they  arc  puzzling. 

The  Prognostic  Significance  of  Abnormal  Temperature. — The  height 
of  the  temperature  is  important,  since  the  danger  increases  with  the  inten- 


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Fever  immediately  relieved  by  in- 
cision and  drainage. 


452  MEDICAL  DIAGNOSIS. 

sity  of  the  fever.  A  rise  of  7.2°  F.  (4°  C.)  or  9°  F.  (5°  C.)  is  of  itself  ominous. 
If  sustained  for  some  hours  death  almost  always  follows,  though  remark- 
able exceptions  to  this  rule  have  been  observed.  Abrupt  rises  from  the 
range  of  health,  such  as  are  seen  in  malaria  or  relapsing  fever,  are  less 
dangerous  than  sudden  rises  above  the  fastigium  in  the  course  of  enteric 
or  other  continued  fever. 

Variations  from  type  in  the  temperature  curve  modify  the  prognosis 
unfavorably.  The  irregular  pneumonias  of  moderate  temperature,  102°  F. 
(38.8°  C.)  are  attended  by  greater  danger  to  life  than  the  typical  forms 
with  intense  fever,  104°  F.  (40°  C.)  or  higher. 

The  temperature  in  childhood  is  less  stable  than  in  adult  life.  It  is 
elevated  by  slight  causes,  and  reacts  more  readily  to  antipyretic  treatment. 
Forms  of  ephemeral  fever  are  more  common  than  in  later  life.  High  tem- 
peratures are  less  dangerous. 


V. 

RESPIRATION;  MODIFIED  RESPIRATORY  MOVEMENTS;  COUGH 

AND  ALLIED  PHENOMENA;    SIGNIFICANCE  OF  COUGH  IN 

DIAGNOSIS;    EXPECTORATION. 

RESPIRATION. 

The  normal  respiration-frequency  in  the  adult  is  from  16  to  24  in  the 
minute.  The  average  pulse-frequency  varies  between  64  and  96.  The 
normal  pulse-respiration  frequency  is  therefore  1  to  4-4.5.  In  early  life 
the  respiration  is  more  rapid,  the  average  being  in  the  new-born  44;  in  the 
fifth  year  26.  Posture  exerts  a  marked  influence.  In  normal  adults  the 
average  frequency  while  recumbent  is  14,  while  sitting  20,  and  in  the  erect 
posture  22.  These  differences  are  exaggerated  in  those  who  are  enfeebled 
by  disease.  The  respiration  is  slightly  less  frequent  in  the  morning  than  at 
night,  and  about  one-fourth  less  during  sleep.  It  is  more  rapid  after  eating 
and  especially  after  a  hearty  meal,  a  fact  which  finds  its  explanation  in 
the  more  limited  excursus  of  the  diaphragm  when  the  stomach  is  full. 
The  rate  is  very  little  influenced  by  the  external  temperature.  It  is  modi- 
fied by  the  internal  temperature  and  much  increased  in  fever.  It  increases 
with  muscular  activity.  The  respiration  frequency  may  be  modified  within 
limits  by  an  effort  of  the  will  and  is  profoundly  affected  by  the  emotions. 
Clinically  the  rate  is  often  quickened  by  the  knowledge  on  the  part  of  the 
patient  that  his  breaths  are  being  counted.  It  is  therefore  important,  if 
possible,  to  count  without  his  being  aware  of  it,  for  instance,  when  you 
appear  to  be  counting  the  pulse.  Failures  of  observation  may  be  controlled 
by  counting  for  one  or  more  entire  minutes.  The  rate  and  depth  of  the 
respirations  bear  an  inverse  relation  to  each  other:  the  greater  the  fre- 
quency the  less  the  depth,  or  the  slower  they  are,  the  deeper.  General 
abnormal  conditions  and  local  diseases,  especially  those  which  involve  the 
organs  of  respiration,  modify  both  the  frequency  and  extent  of  the  respira- 
tory movements. 


SYMPTOMS  AND  SIGNS:    RESPIRATION.  453 

Tidal  Air.— This  term  is  used  to  designate  the  inflow  and  outflow  of 
air  during  quiet  respiration.  It  amounts  to  about  500  cubic  centimetres — 
30  cubic  inches.  Complemental  air  is  the  volume  that  can  be  inspired 
after  the  completion  of  an  ordinary  inspiration;  reserve  or  supplemental 
air,  the  volume  that  can  be  expelled  after  an  ordinary  expiration;  resid- 
ual air,  the  volume  remaining  in  the  lungs  after  the  most  forcible  expira- 
tion; stationary  air,  the  volume  remaining  in  the  lungs  after  an  ordinary 
expiration  and  equal  to  the  reserve  air  plus  the  residual  air.  Vital  ca- 
pacity is  the  volume  of  air  that  can  be  expired  after  the  fullest  inspiration. 
The  average  is  about  3400  cubic  centimetres  for  men  and  2500  cubic  centi- 
metres for  women.  Lung  capacity  is  the  total  quantity  of  air  in  the  lungs 
after  full  inspiration,  and  is  equal  to  the  vital  capacity  plus  the  residual  air. 

Vital  Capacity. — The  measurement  of  the  vital  capacity  is  determined 
by  various  modifications  of  the  spirometer  devised  by  Hutchinson.  It  is 
affected  by  age,  sex,  stature,  posture,  occupation,  and  disease.  It  increases 
with  age,  the  maximum  being  attained  at  about  the  thirty-fifth  year.  It 
is  greater  in  men  than  in  women  of  the  same  height  in  the  ratio  of  10  to 
7.5.  It  increases  in  proportion  to  the  stature  up  to  the  twenty-fifth  year, 
and  Arnold  found  that,  in  the  adult,  for  each  centimetre  of  increase  or 
decrease  of  height  beyond  a  mean  standard  there  is  a  corresponding  rise  or 
fall  in  the  vital  capacity  of  60  cubic  centimetres  for  men  and  40  for  women. 
The  ratio  as  modified  by  posture  is  0.96  in  the  prone,  1.11  in  the  sitting 
or  erect,  and  1.13  in  the  standing  position.  The  vital  capacity  is  greater  in 
those  leading  an  active  than  in  those  who  lead  a  sedentary  life.  It  is 
obvious  that  improper  clothing  and  tight  lacing  and  all  pathological  condi- 
tions which  interfere  with  the  full  and  free  expansion  of  the  chest,  whether 
general,  as  in  wasting  diseases  of  every  kind,  or  local,  as  in  thoracic  or 
abdominal  diseases,  must  diminish  the  vital  capacity;  nor  is  it  to  be  over- 
looked that  pregnancy  or  a  sedentary  life  not  in  itself  incompatible  with 
excellent  health  may  exert  a  similar  influence.  The  spirometer,  partly  for 
these  reasons,  partly  by  reason  of  its  inconvenience  of  application  and  un- 
certainty as  an  instrument  of  precision,  and,  finally,  because  there  are  other 
methods  far  more  available  and  accurate,  has  fallen  wholly  into  disuse  in 
ordinary  clinical  work. 

Peculiarities  in  the  respiratory  phenomena  are  expressed  by  the  fol- 
lowing terms: 

Eupncea  is  a  condition  of  normal  respiration  observed  during  bodily 
and  mental  quiet.  Apncea  is  a  temporary  suspension  of  the  respiratory 
movements.  Hyperpncea  is  a  term  used  to  designate  increased  respiratory 
activity.  Heat-dyspncea  and  polypnea  are  forms  of  hyperpncea  due  to 
direct  excitation  of  the  respiratory  centres,  as  the  result  of  an  increase  in 
the  temperature  of  the  blood  or  of  reflex  excitation  of  the  cutaneous  nerves 
by  external  heat.  Dyspncea  is  difficult  or  labored  breathing;  the  respir- 
atory frequency  is  often  less  than  normal  but  may  be  increased.  As- 
phyxia or  suffocation  is  the  term  used  to  express  the  condition  caused 
by  deprivation  of  air.  The  respirations  are  at  first  increased  in  frequency 
and  depth,  theD  a  period  of  increasing  dyspnoea  follows,  with  violent  spas- 
modic expirations  and  convulsions.  The  final  condition  is  that  of  collapse, 
which  is  ushered  in  by  progressive  slowness  and  shallowness  of  the  respi- 


454  MEDICAL  DIAGNOSIS. 

rations,  dilatation  of  the  pupils,  disappearance  of  the  motor  reflexes,  loss  of 
consciousness,  convulsive  twitching,  and  relaxation  of  the  sphincters.  The 
heart  commonly  continues  to  beat  for  some  minutes  after  the  cessation  of 
breathing,  so  that  by  means  of  artificial  respiration  the  patient  may  be 
restored  to  life.  After  death  the  blood  is  dark,  the  veins  and  lungs 
engorged,  and  the  arteries  empty. 

Type  in  Respiration. — The  filling  of  the  lungs  with  air  is  brought  to  pass 
in  part  by  the  outward  and  upward  movement  of  the  ribs  and  sternum  and 
in  part  by  the  contraction  of  the  diaphragm.  Either  of  these  factors  may 
predominate;  hence  a  costal  type  of  respiration  and  a  diaphragmatic  or 
abdominal  type.  In  women  the  costal  type  is  more  pronounced;  in  men  the 
abdominal.    In  the  new-born  the  type  is  abdominal,  in  older  children  costal. 

The  type  undergoes  modifications  in  consequence  of  various  patho- 
logical conditions  which  affect  the  costal  or  abdominal  respiration. 

Limitation  of  costal  respiratory  movements  is  caused  by  intratho- 
racic disease  or  by  changes  in  the  wall  of  the  thorax.  Dense  pleural  thick- 
ening, pulmonary  consolidation,  loss  of  pulmonary  elasticity,  effusions, 
large  aneurisms,  and  tumors  of  every  kind  limit  the  respiratory  excursus 
in  the  region  involved.  If  one-sided,  as  is  mostly  the  case,  the  unaffected 
lung  takes  upon  itself  additional  work, — vicarious  respiration, — and  the 
increased  respiratory  movement  of  the  sound  side  is  in  strong  contrast  to 
the  restricted  movement  of  the  affected  side.  Calcification  of  the  costal 
cartilages  and  the  ankylosis  of  the  costosternal  articulations,  which  takes 
place  in  arthritis  deformans  and  emphysema,  interfere  with  the  move- 
ments of  the  ribs  and  may  convert  the  costal  type  of  respiration  in  the 
female  or  the  costo-abdominal  in  the  male  into  the  purely  abdominal  type. 

Limitation  of  abdominal  respiration  may  arise  as  the  result  of  mechan- 
ical interference  with  movements  of  the  diaphragm,  paralysis  of  the  dia- 
phragm itself  through  flattening  of  its  vault  by  the  presence  of  pleural 
effusions,  or  in  emphysema,  and  instinctively  to  avoid  pain.  The  costal 
type  may  therefore  be  intensified  and  the  diaphragmatic  diminished  in 
the  following  conditions:  mechanically  in  all  forms  of  marked  distention 
of  the  abdomen,  as  advanced  pregnancy,  tympany,  tumors,  and  ascites; 
acute  inflammations  of  the  serous  membranes  in  relation  with  the  dia- 
phragm, as  pleurisy,  pericarditis,  and  peritonitis — the  limitation  of  move- 
ment being  in  part  the  result  of  pain,  in  part  the  result  of  paresis  of  the 
musculature  of  the  diaphragm;  paralytic  states  involving  the  diaphragm, 
as  multiple  neuritis  or  progressive  muscular  atrophy. 

MODIFIED  RESPIRATORY  MOVEMENTS. 

Derangements  of  the  Frequency  and  Rhythm  of  the  Respiration. — 
(a)  Diminution  in  the  Respiration  Frequency — Oligopnoea. — This  symptom 
is  common  in  stuporous  conditions  and  in  coma.  It  occurs  in  severe 
brain  disorders,  as  hemorrhage,  tumors,  meningitis,  in  uraemia,  diabetic 
coma,  intense  infections,  and  many  forms  of  narcotic  poisoning.  As  disso- 
lution approaches  the  respiration  declines  in  frequency.  In  all  of  these 
conditions  the  rhythm  of  the  respiration  may  be  deranged.  The  changes 
are  due  to  altered  function  of  the  respiratory  centre. 


SYMPTOMS  AXD  SIGXS:  RESPIRATORY   MOVEMENTS.     455 


(b)  Increased  Frequency— Polypnoea. — This  results  from  increased  de- 
mands upon  the  respiratory  function  and  constitutes  an  important  element 
in  the  symptom-complex  dyspnoea.  It  occurs  also  as  a  nervous  symptom 
in  hysteria  and  certain  forms  of  cerebral  disease. 

(c)  Characteristic  Derangements. — 1.  Meningeal  Respiration,  Biot 
Breathing. — This  form  of  breathing,  as  its  name  indicates,  is  common  in 
meningitis,  but  may  occur  in  other  affections  of  the  brain  and  in  severe 
general  infections  and  toxic  conditions.  It  is  characterized  by  pauses  in 
breathing,  which  last  from  a  few  seconds  to  half  a  minute  or  longer  and 
recur  at  regular  or  irregular  periods.  It  is  of  unfavorable  prognostic  import. 
The  characteristics  of  Biot's  respiration  are:  Periods  of  apncea,  which 
vary  in  length  and  occur  at  irregular  intervals;  constant  irregularity  in 
rhythm,  and  in  the  force  of  the  individual  respirations;  the  frequent  occur- 
rence of  deep  sighs;  uniformity  of  the  expiratory  level. 

2.  Cheyne-Stokes  Respiration. — There  are  similar  pauses  in  this 
form  of  breathing.  They  do  not,  however,  occur  as  mere  interruptions  of 
respiration  but  are  preceded  by  a  gradual  diminution  in  the  depth  and 
frequency  of  the  respiratory 
acts  until  breathing  wholly 
ceases.  After  a  pause  of  sev- 
eral or  many  seconds  the 
breathing  is  re-established.  It 
is  at  first  shallow  and  slow, 
but  progressively  increases  and 
becomes  by  degrees  more 
rapid,  deeper,  and  sometimes 
urgent,  until  a  maximum  is 
attained.  Then  follows  another 
gradual  decrease,  to  be  again 
followed  in  time  by  total  arrest 
of  respiratory  movement. 
Cheyne-Stokes  respiration  is 
characterized  by  an  exquisite  periodicity.  It  is  encountered  in  grave  general 
conditions  due  to  affections  of  the  brain,  heart,  or  respiratory  organs,  espe- 
cially in  individuals  who  have  marked  arteriosclerosis.  It  occurs  also 
in  uraemia  and  usually  but  by  no  means  invariably  in  unconsciousness. 
This  form  of  breathing  may  arise  while  consciousness  is  retained,  and  espe- 
cially is  this  the  case  in  chronic  affections  of  the  circulatory  and  respiratory 
organs.  Under  some  circumstances  consciousness  is  partially  or  wholly 
lost  during  the  respiratory  pauses  and  regained  in  the  intervals  of  breath- 
ing. During  the  pauses  there  is  sometime.-,  a  marked  slowing  of  the  pulse, 
with  altered  tension,  and  contraction  of  the  pupils,  but  these  phenomena 
bear  no  constant  relation  to  the  respiratory  changes.  During  the  accel- 
eration in  breathing  which  follows  the  pause  the  patients  in  some  instances 
experience  a  desire  for  air  and  in  other  instances  the  sensation  of  having 
been  roused  from  sleep.  Cyanosis  may  occur  during  the  pause.  In  certain 
cases  Cheyne-Stokes  respiration  occurs  only  in  sleep.  Full  doses  of  mor- 
phine are  followed  by  an  intensification  of  the  phenomena,  and  Cheyne- 
Stokes  respiration  may  first   appear  in  the  sleep  which  follows  the  admin 


Fig.  197. — 1.  Cheyne-Stokes  respiration  pneumato- 
graphy.  2.  Biot's  tracings  illustrating  the  meningitic 
type  of  breathing.  Down  stroke  =  inspiration.  (Am.  Jour. 
Med.  Science,  March,  1911.) 


456  MEDICAL  DIAGNOSIS. 

istration  of  this  drug.  The  prognosis  of  the  underlying  condition  is  always 
grave,  and  this  form  of  respiration  is  seen  in  profound  illness  from  which, 
exceptionally,  the  patient  rallies  in  a  short  time  or,  and  this  is  the  general 
rule,  presently  dies.  In  some  cases  of  cardiac  or  renal  disease,  however, 
Cheyne-Stokes  respiration  recurs  from  time  to  time  for  months. 

3.  Jerking  Respiration. — The  act  may  be  spasmodic.  Usually  it  is 
the  inspiration  that  is  jerking,  less  commonly  the  expiration,  rarely  both. 
Jerking  inspiration  is  seen  in  sobbing,  hysteria,  hydrophobia,,  sometimes 
in  asthma;  jerking  expiration,  in  acutely  painful  respiration,  such  as 
occurs  in  pleurisy,  especially  diaphragmatic,  in  pleurodynia,  or  in  the  case 
of  a  broken  rib.  Jerking  respiration  is  more  apt  to  occur  when  the  breath- 
ing is  of  the  costal  type  than  when  it  is  abdominal. 

Dyspnoea. — This  term  includes  a  variety  of  respiratory  derangements 
which,  much  as  they  may  differ  among  themselves  in  detail,  have  one 
thing  in  common,  namely,  difficulty  in  breathing.  The  clinical  conception, 
whatever  the  cause  or  whatever  the  derangement,  rests  upon  inadequate 
oxygenation  of  the  blood.  Dyspnoea  may  arise  from  a  deficiency  of  oxygen 
or  from  an  excess  of  carbon  dioxide  in  the  blood.  Cardiac  and  hemorrhagic 
dyspnoeas  are  due  chiefly  to  a  deficient  supply  of  oxygen.  In  cardiac  dys- 
pnoea the  poor  supply  of  blood  to  the  tissues  results  from  the  enfeebled  action 
of  the  heart.  In  hemorrhagic  dyspnoea  there  is  enfeebled  action  of  the 
heart  on  the  one  hand  and  a  diminished  quantity  of  blood  on  the  other. 
All  conditions  which  lessen  the  force  of  the  circulation  or  the  quantity  of 
haemoglobin  tend  to  cause  dyspnoea;  hence  individuals  who  suffer  from  car- 
diac lesions  or  forms  of  anaemia,  or  who  are  enfeebled  by  disease,  experience 
difficulty  in  respiration  after  slight  exertion.  Conditions  which  interfere 
with  the  interchange  of  oxygen  and  carbon  dioxide  in  the  lungs,  such  as 
bronchitis  of  the  smaller  tubes,  forms  of  pneumonia,  emphysema,  extensive 
pulmonary  tuberculosis,  laryngeal  obstruction,  abdominal  tumors,  and 
large  ascites,  tend  to  the  production  of  dyspnoea,  especially  upon  exertion. 

The  respiration  may  be  more  or  less  frequent  than  normal.  Two  prin- 
cipal forms  may  be  distinguished,  namely,  that  in  which  the  breathing  is 
rapid  and  shallow  and  that  in  which  it  is  slow  and  deep.  In  the  former  the 
ratio  between  inspiration  and  expiration  is  not  usually  much  deranged; 
difficulty  in  breathing  attends  both  acts  and  the  condition  is  spoken  of  as 
mixed  dyspnoea.  In  the  latter  the  ratio  is  disordered,  sometimes  the  inspi- 
ration, sometimes  the  expiration  being  more  prolonged.  To  the  one  is 
applied  the  term  inspiratory  dyspnoea;  to  the  other  expiratory  dyspnoea. 
The  first  is  characterized  by  inspiratory,  the  second  by  expiratory  stridor. 
In  all  forms  of  dyspnoea  certain  muscles  which  ordinarily  are  little  or  not 
at  all  used  in  respiration  and  have  other  functions  are  brought  into  play. 
They  are  the  auxiliary  muscles  of  respiration.  Among  them  are  the 
scaleni,  trapezii,  levatores  scapulae,  the  sternocleidomastoid,  sterno-  and 
thyrohyoid  muscles,  and  the  pectorales.  The  action  of  these  muscles  is 
more  powerfully  exerted  in  the  6rect  or  sitting  posture — orthopnoea — the 
position  usually  assumed  in  inspiratory  dyspnoea.  In  expiratory  dyspnoea 
the  abdominal  muscles  are  used  as  auxiliary  muscles. . 

In  dyspnoea  of  high  grade  the  muscles  of  facial  expression  are  also 
brought  into  play,  with  the  effect  of  dilating  the  nostrils  and  separating 


SYMPTOMS  AND  SIGNS:   RESPIRATORY  MOVEMENTS.     457 

the  lips  and  jaws.  The  action  of  these  muscles  gives  to  the  facies  a  very 
characteristic  and  distressed  appearance.  Very  striking  is  the  play  of  the 
nostrils  in  young  children  suffering  with  pneumonia.  The  entrance  of  air 
is  to  some  extent  favored  by  the  action  of  these  muscles,  but  the  ex- 
planation of  their  participation  in  the  dyspnceal  movements  is  to  be  sought 
in  the  implication  of  associated  muscle  groups  in  the  intense  innervation 
supplied  to  the  essential  muscles  of  respiration. 

The  term  dyspncea  is  sometimes  used  to  designate  the  sensation  of 
breathlessness  which  attends  difficult  breathing.  Hence  subjective  and 
objective  dyspncea.  These  two  forms  are  usually  associated,  but  to  this 
statement  there  are  exceptions.  Cases  occur  in  which,  with  persistent 
obstruction  of  the  respiration  and  well-marked  objective  dyspncea,  there 
is  no  sense  of  breathlessness  or  oppression.  Cyanosis  may  even  be  present 
without  subjective  dyspncea.  As  death  approaches  and  objective  dyspncea 
becomes  urgent  carbon-dioxide  narcosis  develops  and  subjective  dyspncea 
disappears.  There  are  cases,  however,  in  which  objective  dyspncea  is 
slight  or  absent  altogether,  yet  the  patient  complains  of  distressing  sub- 
jective dyspncea.  To  this  category  must  be  referred  the  precordial  distress 
of  melancholia  and  the  frequent  desire  of  nervous  patients  to  take  a  series 
of  deep  inspirations.     Pure  subjective  dyspncea  is  rare. 

Cyanosis  attends  every  obstruction  to  respiration  of  high  grade,  what- 
ever the  cause.  The  blood  becomes  progressively  richer  in  carbon  dioxide 
and  poorer  in  oxygen.  In  chronic  conditions  attended  with  dyspncea  the 
organism  may  gradually  become  adjusted  to  subnormal  oxygenation  of 
the  blood,  so  that  the  other  functions  are  fairly  well  performed  and  the 
patient,  although  manifestly  dyspnoeic,  especially  upon  exertion,  and  con- 
stantly cyanosed,  has  little  subjective  dyspncea.  On  the  other  hand  a 
similar  degree  of  obstruction  to  respiration,  if  rapidly  established,  is  at- 
tended with  the  most  urgent  and  distressing  dyspnoea. 

Pneumothorax  affords  a  striking  example  of  the  adjustment  of  the 
organism  to  respiratory  disturbances  of  high  grade.  The  sudden  inter- 
ference with  respiration  causes  intense  objective  and  subjective  dyspncea, 
which  gradually  subsides  and  in  many  cases  wholly  disappears  so  long  as 
the  patient  is  at  rest. 

Dyspncea  is  of  much  less  unfavorable  prognosis  when  the  cyanosis  is 
slight  than  when  it  is  deep  and  persistent. 

Forms  of  Dyspnoea. — Dyspncea  as  the  result  of  pain  occurs  in 
pleurisy  and  especially  in  diaphragmatic  pleurisy,  peritonitis,  inflamma- 
tion of  the  diaphragm,  and  in  affections  of  the  intercostal  muscles,  as 
myalgia  and  trichinosis.  Deep  breathing  is  impossible;  the  respirations 
are  shallow  and  hurried.     The  difficulty  is  not  mechanical  but  functional. 

Dyspncea  from  Diminution  of  the  Respiratory  Surface  or  Lim- 
itation of  the  Respiratory  Excursus. — These  conditions  are  commonly 
associated.  They  are  present  in  diseases  involving  the  parenchyma  of  the 
lungs,  such  as  croupous  and  bronchopneumonia,  large  infarcts,  congestion, 
and  the  like;  also  in  those  affections  in  which  the  capacity  of  the  thorax  is 
decreased,  as  pleural  and  pericardial  effusion,  pneumothorax,  tumors, 
massive  hypertrophy  of  the  heart,  and  kyphoscoliosis;  and  finally  when 
ever  the  movements  of  the  chest  are  hindered,  as  in  emphysema,  severe 


458  MEDICAL  DIAGNOSIS. 

thest-pain,  or  spasm  or  palsy  of  the  respiratory  muscles.  Under  these 
circumstances  the  tidal  air  is  diminished  and  the  number  of  respiratory 
acts  is  correspondingly  increased.  In  proportion  as  the  requirements  of  the 
organism  are  thus  satisfied  the  associated  symptoms, — subjective  dysp- 
noea and  cyanosis, — are  slight  or  absent.  Bodily  effort  increases  the  diffi- 
culty. The  deficiency  of  oxygen  asserts  itself  and  these  symptoms  become 
manifest  upon  moderate  exertion.  If  the  condition  be  unilateral,  as  in 
pleural  effusion,  vicarious  respiration  is  established. 

Dyspncba  in  Circulatory  Derangements. — Valvular  lesions  cause 
dyspnoea  when  the  compensation  fails.  Myocardial  changes  act  in  the 
same  way.  There  is  a  transference  of  blood-pressure  from  the  arterial  to 
the  venous  side  of  the  circulation.  The  organs  receive  less  arterial  and 
retain  more  venous  blood  than  normal.  The  circulatory  derangement 
affects  the  respiratory  centre,  with  the  result  that  the  breathing  is  increased 
both  in  frequency  and  depth.  Lesions  of  the  left  side  of  the  heart  cause 
overfilling  not  only  of  the  veins  of  the  general  circulation  but  also  of  those 
of  the  pulmonary  circuit.  The  overfilling  of  the  pulmonary  capillaries, 
which  ultimately  gives  rise  to  brown  induration,  is  an  additional  cause  of 
dyspnoea,  not  so  much  because  of  the  space  occupied  by  the  blood  as  by 
reason  of  the  impairment  of  elasticity  in  the  congested  tissue  of  the  lung. 
The  alveolar  distention  remains  near  the  inspiration  point  and  the  respir- 
atory excursus  is  correspondingly  diminished.  The  loss  of  elasticity  acts 
as  a  direct  hindrance  to  breathing.  The  paroxysmal  attacks  of  dyspnoea 
in  such  cases  constitute  so-called  cardiac  asthma.  This  .term  is  frequently 
used  to  describe  any  shortness  of  breath  occurring  in  disease  of  the  heart. 
It  is  preferable  to  restrict  it  to  the  attacks  which  bear  a  close  resemblance 
to  true  bronchial  asthma.  Such  attacks  often  come  on  at  night  after  the 
first  sleep.  In  both  conditions  the  form  of  dyspnoea  is  the  same.  There  is 
a  tendency  to  prolongation  of  the  respiratory  act  with  difficult  and  pro- 
longed expiration  attended  by  stridor.  To  the  habitual  overfilling  of  the 
pulmonary  capillaries  in  mitral  disease  must  be  ascribed  the  dyspnoea 
upon  exertion  which  is  so  common  in  this  condition  in  the  absence  of 
impaired  compensation.  A  further  cause  of  dyspnoea  in  circulatory  dis- 
turbances is  the  bronchial  catarrh  which  is  present  to  some  degree  in  most 
of  the  cases. 

Dyspnoea  in  Obstruction  of  the  Upper  Air-passages. — The  stress 
upon  the  inspiratory  muscles  is  proportionate  to  the  degree  of  obstruction. 
The  respiration  tends  to  become  prolonged  and  deep.  In  many  cases,  how- 
ever, it  is  increased  in  frequency  and  correspondingly  superficial.  This  form 
of  dyspnoea  is  present  in  the  marked  stenosis  of  the  pharynx  which  occurs 
as  the  result  of  hypertrophy  of  the  tonsils  or  retropharyngeal  abscess,  in 
spasmodic  and  membranous  laryngitis,  in  oedema  or  spasm  of  the  glottis, 
in  paresis  of  the  abductor  muscles  of  the  larynx  (posterior  crico-arytenoids) 
and  in  narrowing  of  the  pharynx  and  trachea  by  tumors,  foreign  bodies,  and 
compression  from  outside,  as  in  the  case  of  aneurism  or  mediastinal  tumor. 

As  the  obstruction  reaches  a  high  grade  the  volume  of  air  in  the  lungs 
is  progressively  diminished  and  the  less  rigid  portions  of  the  thorax  yield 
to  the  pressure  of  the  external  atmosphere.  The  depressions  are  especially 
marked  in  the  epigastrium  and  the  suprasternal  and  postclavicular  regions. 


SYMPTOMS  AND  SIGNS:    RESPIRATORY  MOVEMENTS.     459 

in  young  children,  in  consequence  of  repeated  attacks  of  laryngitis  or 
bronchitis  the  cartilaginous  portions  of  the  wall  of  the  thorax  yield  and 
more  or  less  persistent  deformities  of  the  chest  arise.  Among  these  are  the 
wide,  shallow,  oblique  depressions  at  the  base  of  the  chest  known  as  Harri- 
son's furrows,  and  the  prominence  of  the  sternum,  known  as  chicken-breast. 

The  stridor  in  this  form  of  dyspncea  is  characteristic.  It  is  commonly 
loud,  prolonged,  and  hissing:  or  whistling  in  character  and  usually  much  more 
aiarKea  upon  inspiration  than  upon  expiration, — a  fact  that  finds  explana- 
tion in  the  lateral  drawing  together  of  the  tissues  below  the  seat  of  obstruc- 
tion in  consequence  of  the  tendency  to  vacuum  caused  by  the  powerful 
inspiratory  effort  and  the  greater  force  of  the  inspiration  as  compared  with 
the  expiration.  In  fact  stridor  may  be  wholly  absent  during  the  expiration. 
'When,  however,  patients  suffering  from  stenosis  of  the  upper  air-passages  in 
increasing  obstruction  become  obliged  to  use  the  abdominal  muscles  in 
active  expiration,  expiratory  stridor  becomes  marked  or  predominant. 

Dyspncea  ix  Bronchitis. — Dyspncea  arises,  as  a  rule,  only  in  those 
cases  in  which  the  catarrhal  inflammation  involves  the  finer  tubes.  The 
lumen  is  narrowed  by  swelling  of  the  mucosa  and  the  presence  of  secretion 
or  exudate.  If  the  narrowing  involves  a  limited  number  of  bronchial 
tubes  the  difficult}"  in  breathing  is  not  urgent  and  compensation  takes 
place  by  increase  in  the  respiration  frequency.  When  the  obstruction  in- 
volves a  great  number  of  bronchial  tubes  differences  in  type  of  the  dyspncea 
arise  which  depend  upon  the  degree  of  obstruction.  In  so-called  capillary 
bronchitis  the  respiratory  surface  is  diminished  to  an  extent  correspond- 
ing with  the  number  and  distribution  of  the  lobules  involved;  dyspncea 
with  hurried  respiration  then  results.  In  the  dry  bronchitis  of  the  middle- 
sized  tubes  it  is  yet  possible  for  a  sufficient  quantity  of  air  to  be  drawn 
into  the  lungs.  This  can  generally  be  accomplished  best  by  respiration  of 
diminished  frequency  and  abnormal  depth,  just  as  in  stenosis  of  the  larynx. 

Dyspnoea  ix  Bronchial  Asthma. — The  breathing  is  slow,  the  ex- 
piration usually  prolonged  and  accompanied  with  stridor — expiratory 
dyspncea.  The  rales  can  be  heard  at  a  considerable  distance  from  the 
patient.  The  difficulty  is  not  to  get  the  air  into  the  lungs  but  to  get  it 
out.  Acute  emphysema  occurs  and  the  respiratory  excursus  is  greatly 
diminished;   hence  the  "air  hunger." 

Dyspncea  ix  Emphysema. — The  chest  tends  to  assume  permanently 
the  inspiratory  form.  The  elasticity  of  the  lung  parenchyma  is  impaired. 
The  respiratory  excursus  is  correspondingly  diminished.  The  alveolar 
septa  are  in  many  places  destroyed,  together  with  the  intra-alveolar  blood- 
vessels. The  breathing  is  shallow  and  frequent.  The  patient  is  distressed 
for  breal  h.  especially  upon  the  slightest  exertion.  The  dyspnoea  is  increased 
by  the  bronchitis  which  is  so  common  in  emphysema.  .Modifications  arise  in 
consequence  of  the  frequent  occurrence  of  bronchial  asthma  in  emphysema. 

So-called  Uremic  Dyspnoea. — This  form  may  occur  as  a  true  ure- 
mic bronchial  asthma.  There  is  slowing  of  the  respiration  with  prolonged 
expiration  and  expiratory  stridor.  The  condition  is  not  common.  The 
dyspnoea  in  the  majority  of  the  cases  is  not  actually  ursemic  but  rather  a 
manifestation  of  cardiac  derangement,  bronchial  catarrh,  or  beginning 
pulmonary  oedema. 


460  MEDICAL  DIAGNOSIS. 

The  Dyspncea  of  Fever. — Rise  of  temperature  is  usually  associated 
with  increase  in  respiration  frequency.  Artificial  elevation  of  temperature 
also  causes  hurried  breathing.  The  dyspncea  is  doubtless  due  to  the  action 
of  heated  blood  upon  the  respiratory  centre.  As  it  bears  no  constant  rela- 
tion to  the  height  to  which  the  temperature  rises,  it  is  probably  due,  in 
part  at  least,  to  the  action  of  the  fever-producing  toxins.  Experience  has 
shown  that  febrile  diseases  in  which  the  respiration  frequency,  in  the 
absence  of  lung  complications,  is  very  high,  are  as  a  rule  of  serious  import. 

The  Dyspncea  of  Anemia. — When  the  haemoglobin  is  diminished, 
the  oxygen  requirement  of  the  organism  demands  the  most  complete  per- 
formance of  the  respiratory  function.  There  is  no  hindrance  to  respiration 
and  the  breathing  is  quickened  and  increased  in  depth.  This  form  of 
dyspncea  is  characteristic  of  high  grades  of  secondary  anaemia  such  as 
occur  in  hemorrhage,  in  advanced  pernicious  anaemia,  and  in  chlorosis, 
following  exertion.  It  is  a  symptom  of  internal  hemorrhage  and  occa- 
sionally of  hemorrhagic  pancreatitis. 

COUGH  AND  ALLIED  PHENOMENA. 

The  normal  rhythmical  expansions  and  contractions  of  the  thorax 
serve  the  physiological  purposes  of  respiration.  Certain  other  move- 
ments which  are  respiratory  in  character  serve  other  purposes.  Of  these 
some  are  voluntary,  others  involuntary,  some  purposeful,  others  spasmodic. 
Among  such  movements  are  the  following: 

Cough. — A  more  or  less  deep  inspiration  is  followed  by  an  expira- 
tory act  which  is  interrupted  by  repeated  partial  closure  of  the  glottis  and 
the  production  of  a  series  of  characteristic  sounds.  The  air  is  expelled 
through  the  narrowed  glottis  with  some  force  so  that  foreign  bodies,  such 
as  a  crumb,  mucus  in  the  respiratory  passages,  and  the  like,  are  swept  from 
the  upper  air-passages  into  the  mouth.  In  the  great  majority  of  cases 
cough,  whether  in  consequence  of  lesions  of  the  respiratory  organs  or  dis- 
ease or  irritation  in  distant  organs,  is  reflex  and  spasmodic.  It  may  be 
voluntarily  produced. 

Hawking  is  a  voluntary  act,  the  result  of  irritation  in  the  pharynx.  It 
resembles  cough  except  that  the  glottis  is  open  and  the  expiration  continuous. 

Sneezing  consists  in  a  deep  inspiration  followed  by  a  forcible  expira- 
tory blast  through  the  nose;  the  glottis  is  open  and  the  mouth  usually 
but  not  always  closed.  Sneezing  is  excited  by  irritation  of  the  terminal 
fibres  of  the  nasal  branches  of  the  fifth  pair  of  cranial  nerves  and  is  often 
preceded  by  peculiar  sensations  in  the  nose. 

Laughing  is  an  emotional  act  characterized  by  deep  inspiration  suc- 
ceeded by  repeatedly  interrupted  expiration  with  an  open  glottis  and 
vibrating  vocal  cords.  The  mouth  is  wide  open,  the  expiration  is  much  less 
forcible  than  in  coughing,  and  the  muscles  of  expression  give  a  character- 
istic appearance  to  the  face.  Laughing  may  be  voluntary  or  involuntary. 
When  very  violent  and  repeated  it  may  be  spasmodic  and  accompanied 
by  tears. 

Crying  closely  resembles  laughing.  It  cannot  in  fact  always  be  dis- 
tinguished from  laughing  and  the  one  may  readily  alternate  with  the  other 


SYMPTOMS  AND  SIGNS:   COUGH.  461 

in  young  children  or  patients  suffering  from  hysteria.  The  rhythm  and 
the  facies  are  different.    Crying  is  involuntary  and  accompanied  by  tears. 

Sobbing  follows  long  spells  of  crying  or  is  the  expression  of  deep 
grief.  It  is  characterized  by  interrupted  inspirations  with  a  partially 
closed  glottis,  followed  by  a  prolonged  quiet  expiration,  and  is  usually 
involuntary. 

Sighing  consists  in  a  prolonged  inspiration  attended  by  a  character- 
istic soft  sound.  The  mouth  is  closed  or  the  lips  but  slightly  parted;  it 
is  largely  voluntary. 

Yawning  consists  in  a  prolonged  deep  inspiration  through  the  widely 
opened  mouth  accompanied  by  a  peculiar  sound.  The  glottis  is  open  and 
the  expiration  short.  The  arms  are  thrown  out  and  the  shoulders  back. 
It  may  be  either  voluntary  or  involuntary  but  is  not  spasmodic. 

Snoring  occurs  during  sleep.  The  mouth  is  open  and  the  relaxed 
palate  is  thrown  into  vibration  by  the  in-  and  outflowing  air.  The  sound 
is  louder  during  inspiration.  It  is  much  more  liable  to  occur  when  the 
sleeper  is  on  his  back. 

Stertor  or  stertorous  breathing  resembles  snoring.  It  occurs  in 
apoplectic  and  oilier  comatose  states,  as  cerebral  concussion,  fracture  of 
the  skull,  epilepsy,  deep  ansesthesia,  alcoholic  stupor,  poisoning  by  opium, 
illuminating  gas,  and  other  narcotics,  pulmonary  oedema,  and  all  conditions 
in  which  excessive  amounts  of  mucus  or  fluid  are  accumulated  in  the 
bronchi,  and  frequently  in  the  death-agony.  Among  the  varieties  of  ster- 
tor are  buccal,  characterized  by  vibrations  of  the  lips  and  puffing  of  the 
relaxed  cheeks  during  expiration;  palatine,  in  which  the  soft  palate  vibrates 
with  the  in-going  and  out-going  air;  pharyngeal,  caused  by  the  sinking 
back  of  the  base  of  the  relaxed  tongue  into  near  relation  with  the  posterior 
wall  of  the  pharynx;  mucous,  the  coarse  snoring  sound  produced  by  the 
churning  of  the  respiratory  air  through  fluid,  such  as  mucus  or  blood  in  the 
trachea  or  larger  bronchial  tubes. 

Stridor  or  stridulous  breathing  is  that  noisy  form  of  breathing  caused 
by  obstruction  in  the  larynx  or  trachea.  This  symptom  may  be  present  in 
croup  and  diphtheria,  oedema  of  the  glottis,  laryngeal  tumors,  mediastinal 
new  growths,  and  aortic  aneurism.  Stridor  due  to  laryngeal  obstruction  is 
commonly  accompanied  by  aphonia.  It  varies  greatly  in  character,  being 
harsh,  musical,  or  crowing. 

Hiccough  is  caused  by  a  sudden  spasmodic  contraction  of  the  dia- 
phragm accompanied  by  closure  of  the  glottis.  There  is  a  peculiar  abrupt 
sound  and  a  distressing  sensation  of  jerking  in  the  epigastrium.  It  is  due 
to  irritation  of  the  terminal  filaments  of  the  phrenic  nerve,  which  may  be 
direct  or  reflex.  It  may  occur  as  the  result  of  gastric  or  peritoneal  irrita- 
tion or  may  be  the  manifestation  of  a  derangement  of  the  nervous  system. 
Hiccough  is  occasionally  observed  after  excessive  or  injudicious  eating  or 
drinking,  in  gastric  disorders,  peritonitis,  the  so-called  typhoid  state,  and 
ura?mia.  It  occurs  also  in  hysteria  and  may  constitute  a  pure  neurosis. 
The  hiccough  of  cerebral  disease,  as  hydrocephalus  or  meningitis,  is  doubt- 
less the  result  of  irritation  of  the  central  origin  of  the  phrenic  nerve.  The 
writer  knows  a  gentleman  in  whom  certain  kinds  of  tobacco  invariably 
produce  distressing  hiccough,  while  others  can  be  smoked  with  impunity. 


462  MEDICAL  DIAGNOSIS. 

Persistent  and  intractable  hiccough  occasionally  attends  the  closing  days  of 
fatal  illness  and  in  rare  instances,  occurring  as  a  neurosis,  has  caused  death 
by  exhaustion. 

Of  all  the  special  or  modified  respiratory  movements  cough  has  the 
most  important  bearing  upon  diagnosis  and  therefore  requires  more  ex- 
tended consideration. 

SIGNIFICANCE  OF  COUGH  IN  DIAGNOSIS. 

Etiological  Considerations. — Reflex  Cough. — Cough  in  the  vast  ma- 
jority of  instances  is  the  result  of  reflex  irritation  of  the  terminal  nerve  fila- 
ments of  the  vagus  distributed  to  the  respiratory  tract.  Irritation  of  the 
mucous  membrane  of  the  larynx  above  the  vocal  cords  does  not  produce 
cough  but  causes  gagging,  while  irritation  below  the  cords  gives  rise  to 
cough.  Especially  sensitive  areas  are  the  interarytenoid  space  and  the 
region  of  the  bifurcation,  while  the  general  mucous  membrane  of  the 
trachea  and  bronchi  shows  a  scarcely  inferior  irritability.  Lesions  of  the 
lung  parenchyma  probably  do  not  cause  cough,  though  they  are  usually 
connected  with  pathological  conditions  of  the  bronchi.  Pleural  irritation 
is  commonly  attended  by  this  symptom.  The  aspiration  of  a  pleural 
exudate  is  frequently  followed  by  prolonged  and  violent  cough. 

Irritation  of  the  nasal  mucosa,  which  is  supplied  with  sensory  nerve- 
twigs  from  the  trigeminus,  may  in  neurotic  individuals  produce  coughing 
with  lachrymation,  as  in  rose  cold,  hay  fever,  and  similar  conditions.  In 
such  persons  the  slightest  touch  of  the  probe  in  the  sensitive  areas  may 
provoke  violent  attacks  of  coughing.  Less  common  is  cough  as  a  symp- 
tom of  hypertrophic,  atrophic,  or  vasomotor  rhinitis  or  of  polypi  or  devia- 
tions of  the  septum.  The  inhalation  of  dust  or  smoke,  irritating  chemical 
fumes,  as  those  of  ammonia,  bromine,  or  pungent  substances,  as  pepper, 
produces  cough  in  a  normal  respiratory  mucous  membrane.  Violent 
paroxysmal  cough  is  excited  by  the  insufflation  of  a  foreign  body,  as  a 
crumb  or  a  drop  of  liquid,  into  the  larynx  or  through  the  glottis.  The 
common  source  of  irritation  is  to  be  found  in  a  morbid  condition  of  the 
mucous  membrane  of  the  larynx,  trachea,  or  bronchi.  There  may  be 
merely  inflammation  and, hyperesthesia  with  altered  or  deficient  secretion; 
an  exudate  of  varying  consistence,  from  the  thin  fluid  of  bronchorrhoea  to 
the  tough  masses  of  tenacious  mucus  in  the  early  stages  of  acute  bron- 
chitis; or  the  solid  bronchial  casts  of  the  terminal  tubules  in  croupous 
pneumonia  or  fibrinous  bronchitis;  or,  finally,  the  material  in  the  bronchi 
may  be  derived  from  adjacent  structures  and  consist  of  blood,  as  in  broncho- 
pulmonary hemorrhage  or  an  aneurism,  or  pus  from  an  empyema,  a  sub- 
phrenic abscess,  or  an  abscess  of  the  liver. 

Cough  Occurs  as  a  Symptom  in  AH  Forms  of  Respiratory  Catarrh. — 
In  acute  or  subacute  rhinitis  it  is  often  associated  with  sneezing;  in  laryn- 
gitis with  hoarseness  or  aphonia;  in  tracheitis  or  tracheobronchitis  with 
substernal  pain;  in  bronchitis  of  the  larger  tubes  with  tickling  sensations 
in  the  early  stages  and  a  mucopurulent  expectoration  later;  in  bronchitis 
of  the  smaller  tubes  with  dyspnoea  and  a  tendency  to  cyanosis;  in  pneu- 
monia with  fever  and  other  indications  of  acute  illness;   in  pleurisy  with  a 


SYMPTOMS  AND  SIGNS:   COUGH  IN  DIAGNOSIS.  463 

3titch  in  the  side.  Cough  is  a  prominent  symptom  in  bronchiectasis  and 
in  all  diseases,  both  acute  and  chronic,  in  which  the  respiratory  mucous 
membrane  is  primarily  in  a  morbid  condition  or  is  irritated  by  the  presence 
of  exudates  or  discharges  from  the  alveolar  tissues  or  other  sources.  The 
irritation  is  always  mechanical,  often  also  chemical.  Cough  is  therefore  a 
constant  and  suggestive  symptom  in  pulmonary  tuberculosis  in  all  its 
forms  and  at  all  stages  of  its  progress.  Cough  is  at  once  the  reflex  response 
to  the  irritation  and  the  effort  to  remove  the  cause  of  the  irritation,  and 
ceases  when  the  effort  is  successful.  The  offending  substance  ejected  is 
known  as  expectoration,  phlegm,  or  sputum,  or,  in  the  plural,  sputa. 

Exceptionally  there  are  cases  in  which,  with  the  most  pronounced 
symptoms  and  signs  of  disease  of  the  lungs,  cough  is  wholly  absent.  This 
may  occur  in  the  low  fevers,  the  pneumonia  of  drunkards,  the  cachectic, 
or  the  aged,  in  cerebral  disease,  and  shortly  before  death.  The  reflexes  are 
obtunded  and  bronchial  secretion  or  an  exudate,  the  presence  of  which  is 
manifested  by  rales,  fails  to  excite  cough.  The  sudden  cessation  of  cough 
in  grave  cases  of  pneumonia  or  advanced  phthisis  is  an  ominous  sign. 
Cough  is  sometimes  absent  because  the  bronchial  secretion  is  swept  on- 
ward by  the  ciliated  epithelium  to  the  larynx  and  removed  by  hawking. 
If  it  is  then  swallowed,  as  is  a  frequent  occurrence,  not  only  is  cough  absent 
but  also  expectoration. 

Much  less  common  is  cough  due  to  extrarespiratory  irritation.  The 
sufferers  are  usually  neuropathic. 

Pharyngeal  Cough. — Tickling  of  the  wall  of  the  pharynx  or  the  base  of 
the  tongue,  which  in  most  persons  is  resented  by  gagging,  in  some  is  fol- 
lowed by  cough.  Lymphoid  growths  in  the  nasopharynx  and  collections 
of  thick  mucus,  or  the  presence  of  inflammatory  exudates,  may  be  the 
cause  of  cough.  Elongation  of  the  uvula  and  paresis  of  the  palate  may 
excite  cough  by  producing  irritation  of  the  posterior  wall  of  the  pharynx, 
especially  during  recumbency.    ' 

Ear  Cough. — Not  infrequently  paroxysmal  cough  is  produced  by  the 
presence  of  a  foreign  body  in  the  external  auditory  meatus  or  by  disease 
of  that  passage.  The  mere  introduction  of  the  speculum  may  cause  cough 
so  violent  as  to  make  the  examination  most  difficult.  The  afferent  nerve 
is  the  auricular  branch  of  the  pneumogastric  or,  according  to  others,  the 
auriculotemporal  branch  of  the  fifth  nerve. 

Stomach  Cough. — The  popular  explanation  of  certain  forms  of  cough 
as  a  manifestation  of  disorders  of  the  stomach  is  sustained  neither  by 
pathological  nor  experimental  investigation.  The  morning  cough  of  the 
drunkard  is  to  be  accounted  for  by  the  pharyngeal  catarrh  which  accom- 
panies chronic  alcoholic  gastritis;  of  the  consumptive,  by  lesions  of  the 
lungs  or  larynx,  with  which  secondary  gastric  disorders  are  commonly 
associated.  The  cough  occasionally  observed  in  subacute  catarrhal  gas- 
tritis and  which  disappears  as  the  gastritis  improves  is  due  to  the  asso- 
ciated pharyngitis.  Bronchitis  is  very  common  in  chronic  alcoholism  and 
other  forms  of  ill  health  with  derangement  of  the  gastro-intestinal  tract, 
and  a  careful  investigation  of  the  cases  of  so-called  stomach  cough  will 
almost  always  demonstrate,  with  the  gastric  condition,  associated  lesions 
of  the  respiratory  tract  which  account  for  this  symptom. 


464  MEDICAL  DIAGNOSIS. 

Liver  Cough. — This  symptom  is  doubtless  due  to  irritation  of  the 
diaphragmatic  pleura.  It  is  met  with  in  certain  cases  of  hypertrophy  of  the 
liver,  perihepatitis,  hydatids,  and  hepatic  and  subphrenic  abscess. 

Disease  or  enlargement  of  the  spleen  may  also  in  rare  cases  be  the 
cause  of  cough. 

Cough  may  exceptionally  be  provoked  by  pressure  in  the  region  of  the 
liver  or  spleen. 

For  some  years  the  writer  had  under  observation  a  case  of  ventral 
hernia  midway  between  the  tip  of  the  ensiform  cartilage  and  the  umbilicus 
in  the  median  line,  in  which  violent  paroxysmal  cough  attended  the  pres- 
ence of  the  tumor  and  immediately  subsided  upon  its  reduction. 

Dentition. — Cough  is  not  uncommon  during  the  first  dentition,  with- 
out manifestations  of  disease  of  the  respiratory  tract.  It  appears  before 
the  eruption  of  the  successive  groups  of  teeth  and  disappears  with  the 
completion  of  the  process. 

Mediastinal  Cough. — Mediastinal  tumor  or  abscess,  thoracic  aneurism, 
enlarged  bronchial  glands,  and  caries  of  the  dorsal  vertebrae  are  occasional 
causes  of  persistent  and  troublesome  cough.  Massive  hypertrophy  or  great 
dilatation  of  the  heart  is  also  in  some  instances  accompanied  by  cough. 

Nervous  Cough. — The  diagnosis  of  nervous  cough  is  only  to  be  made 
when,  in  default  of  direct  signs  or  symptoms  or  by  exclusion,  the  absence 
of  disease  of  the  respiratory  organs  or  other  lesions  recognized  as  the  cause 
of  this  symptom  can  be  established.  Not  rarely  cough  is  the  only  direct 
manifestation  of  a  bronchitis  or  pulmonary  tuberculous  process  in  which, 
for  the  time  being,  the  ordinary  physical  signs  are  lacking.  It  often  hap- 
pens that  the  diagnosis  of  nervous  cough  is  made  when  the  intensity  and 
persistence  of  the  cough  is  altogether  out  of  proportion  to  its  actual  physical 
cause,  as  is  common  in  neurotic  individuals.  Nevertheless  in  some  cases 
cough  must  be  recognized  as  a  purely  nervous  phenomenon.  There  are 
persons  who  cough  whenever  their  feet  are  chilled  or  a  cold  air  blows 
upon  an  exposed  part  of  the  body.  Paroxysmal  cough  of  purely  nervous 
nature  is  not  uncommon  in  both  sexes  at  puberty.  Cough  is  one 
of  the  multitudinous  symptoms  of  hysteria.  Under  certain  conditions 
cough  may  occur  in  neurotic  individuals  in  consequence  of  disease  or  irri- 
tation of  the  mamma?  or  of  the  genital  organs  in  either  sex.  It  has  been 
shown  that  cough  may  be  excited  by  irritation  of  the  floor  of  the  fourth 
ventricle  above  the  centre  for  respiration.  Whether,  under  pathological 
conditions,  a  true  "centric  cough"  occurs  is  open  to  question.  Irritation 
of  a  "cough  centre"  has  been  invoked  to  explain  hysteincal  and  other 
coughs  of  purely  nervous  origin. 

Clinical  Varieties  of  Cough. — The  character  of  the  cough  is  of  impor- 
tance in  diagnosis.  It  is  modified  according  to  the  seat  of  the  irritation, 
whether  respiratory  or  extrarespiratory;  by  the  anatomical  structure 
involved,  as  the  larynx,  bronchi,  pleura;  by  the  amount  and  consistence 
of  the  irritating  substance;  and  by  the  constitutional  peculiarities  of  the 
patient.    The  following  forms  demand  especial  consideration: 

Dry  Cough. — Patients  themselves  recognize  the  distinction  between 
dry  and  moist  cough.  Cough  due  to  irritation  of  the  respiratory  mucous 
membrane  is  dry  when  it  occurs  in  the  absence  of  secretion  or  if  the  secre- 


SYMPTOMS  AXD  SIGNS:   COUGH  IN  DIAGNOSIS.  465 

tion  is  tough,  tenacious,  and  not  readily  dislodged.  Extrarespiratory 
cough — so-called  "  reflex  cough" — is  dry.  The  sound  is  hacking,  barking,  or 
ringing  and  is  not  accompanied  by  expectoration.  Dry  cough  is  frequently 
spoken  of  as  "unproductive."  It  occurs  in  the  early  stage  of  acute  bron- 
chitis, bronchial  asthma,  influenza,  pneumonia,  and  pleurisy,  in  affections 
of  the  upper  air-passages,  phthisis,  and  pertussis.  This  is  the  cough  which 
is  excited  by  the  inhalation  of  foreign  bodies,  irritating  fumes,  or  dust,  and 
by  extrarespiratory  causes.  It  results  from  pleural  irritation  and  is 
encountered  in  pleurisy  with  fibrinous  exudate  and  upon  the  withdrawal 
of  an  effusion. 

Loose  or  Moist  Cough. — This  cough  is  associated  with  sounds  indi- 
cating the  part  played  by  fluid  in  the  mechanism  of  its  production.  It 
differs  from  dry  cough  not  only  in  its  acoustic  characters  but  also  in  the 
occurrence  of  expectoration.  It  is  "productive."  Loose  cough  occurs  in 
the  later  stages  of  acute  bronchitis,  influenza,  and  pneumonia;  toward  the 
close  of  the  paroxysms  of  whooping-cough  and  asthma;  in  chronic  bron- 
chitis, bronchiectasis,  and  pulmonary  gangrene;  in  advanced  phthisis; 
and  in  all  conditions  attended  by  moderate  or  abundant  bronchial  secretion. 

Constant  and  Recurrent  Cough. — Adjectives  such  as  constant,  per- 
sistent, recurrent,  designate  peculiarities  of  the  cough  dependent  upon 
the  persistence  or  recurrence  of  its  cause.  So-called  nervous  cough  is 
usually  persistent;  also  the  cough  which  attends  diseases  of  the  upper  air- 
passages  and  acute  bronchitis  and  that  of  bronchorrhcea.  On  the  other 
hand,  in  chronic  bronchitis,  especially  when  there  is  bronchial  dilatation, 
the  cough  is  apt  to  occur  paroxysmally  at  varying  intervals.  The  expec- 
toration of  a  large  amount  of  matter  is  followed  by  relief.  After  a  time 
the  secretion  reaccumulates,  a  mere  overflow  into  the  bronchi  on  change 
of  posture  excites  cough,  and  the  process  is  repeated.  This  form  of  cough 
attends  the  later  stages  of  phthisis  with  large  vomica?  and  occurs  in  some 
cases  of  empyema  with  bronchopulmonary  fistula.  Recurrent  cough  is 
very  common  in  chronic  bronchitis  and  phthisis;  it  constitutes  the  "morn- 
ing cough"  of  these  conditions.  The  secretion  accumulates  slowly  during 
sleep  without  exciting  irritation.  On  waking,  the  patient  moves,  the 
accumulated  material  shifts  its  position  a  little,  the  bronchial  reflex  is 
brought  into  play,  cough  results  and  continues  until  the  offending  mass  is 
expelled. 

Paroxysmal  Cough.  —  Recurrent  cough  is  not  necessarily  paroxysmal, 
and  paroxysmal  cough  for  the  time  may  be  constant.  The  word  paroxysm 
conveys  the  idea  of  suddenness  and  intensity.  Such  is  the  cough  of  acute 
inflammatory  conditions;  that  caused  by  foreign  bodies  in  the  air-passages, 
the  insufflation  of  saliva,  and  the  like;  by  the  periodical  flooding  of  the 
bronchi  with  the  abundant  contents  of  the  cavities  in  phthisis,  bronchial 
dilatation,  pulmonary  abscess,  or  gangrene;  and  finally  that  of  pertussis. 
The  paroxysm  recurs  at  intervals  varying  from  an  hour  or  less  to  once  a 
day  or  longer.  In  the  case  ol  cavities  or  a  bronchial  fistula  in  empyema 
the  interval  is  determined  by  the  accumulation;  in  pertussis  by  the  inten- 
sity of  the  neurosis.  In  the  latter  condition  the  cough  is  characteristic. 
Into  its  production  two  factors  enter:    an  abundant   tenacious  mucus  and 

a  pathological  nervous  excitability.    After  a  long  inspiration,  the  expira- 

30 


466  MEDICAL  DIAGNOSIS. 

tory  cough-efforts  succeed  each  other  with  such  rapidity  that  inspiration 
is  partial  or  absent  until  at  last  a  prolonged  inspiration  takes  place  which, 
by  reason  of  the  spasmodic  contraction  of  the  glottis,  is  attended  by  a 
harsh,  crowing  sound  or  whoop;  hence  the  common  term  whooping-cough. 
A  somewhat  similar  inspiratory  whoop  sometimes  attends  the  paroxysmal 
cough  of  other  diseases,  but  so  infrequently  that  in  the  vast  majority  of 
cases  the  phenomenon  justifies  the  diagnosis  of  whooping-cough.  The 
differential  diagnosis  involves  consideration  of  the  age  of  the  patient,  the 
presence  or  absence  of  an  epidemic,  history  of  exposure,  the  duration  and 
course  of  the  attack,  and  the  presence  or  absence  of  lesions  capable  of 
causing  violent  paroxysmal  cough  other  than  that  of  pertussis.  The  cough 
which  attends  enlargement  of  the  bronchial  .glands,  mediastinal  tumor, 
caries  of  the  dorsal  vertebra?,  enlargement  of  the  heart,  and  pericardial 
effusion  is  paroxysmal  and  dry.  Quite  often  it  has  the  laryngeal  character. 
Very  violent  paroxysms  of  cough  frequently  result  in  retching  and  vomit- 
ing and,  as  a  result  of  the  venous  congestion  from  intrathoracic  pressure, 
in  hemorrhage  from  mucous  surfaces  or  into  the  skin. 

Croupy  Cough. — A  dry  cough,  described  as  metallic,  ringing,  or  croupy, 
is  characteristic  of  laryngeal  irritation.  The  voice  is  usually  hoarse  or 
aphonic,  though  it  may  be  unimpaired.  The  laryngeal  cough  occurs  in 
simple  or  exudative  laryngitis,  spasm  of  the  larynx,  from  the  inhalation  of 
smoke  or  dust,  as  the  result  of  the  irritation  produced  by  foreign  bodies 
in  the  larynx,  and  in  tuberculous,  syphilitic,  or  cancerous  ulceration. 
The  cough  of  hysteria  is  usually  laryngeal  in  character,  though  upon  laryn- 
goscopical  examination  neither  swelling  nor  paralysis  may  be  present. 
It  is  described  by  such  adjectives  as  barking  or  croaking  and  resembles 
other  hysterical  manifestations  by  the  readiness  with  which  it  may  be 
voluntarily  produced.  A  barking  laryngeal  cough,  in  the  absence  of  swell- 
ing of  the  laryngeal  mucosa  or  paralysis  of  the  vocal  cords  or  of  lesions 
directly  or  indirectly  involving  the  recurrent  laryngeal  nerves,  is  commonly 
hysterical. 

Suppressed  Cough.  —  Voluntary  efforts  to  suppress  cough  are  made 
under  circumstances  in  which  the  sound  of  the  cough  is  likely  to  annoy 
others  and  when  the  act  is  attended  by  pain,  as  in  pleurisy,  acute  perito- 
nitis, and  some  forms  of  acute  bronchitis.  The  suppressed  cough  is  usually 
lacking  in  tone,  and  is  explosive  and  persistent. 

Undeveloped  Cough. — Incomplete  efforts  at  cough,  unattended  by 
the  characteristic  sound,  are  observed  in  cases  of  destructive  ulceration 
or  paralysis  of  the  vocal  cords  or  of  partial  paralysis  of  the  expiratory 
muscles.  This  form  of  cough  is  encountered  in  laryngeal  phthisis,  in  pa- 
tients suffering  from  bulbar  paralysis,  in  enormous  ascites  or  abdominal 
tumors,  and  in  conditions  attended  with  extreme  debility,  especially  the 
later  stages  of  croupous  and  bronchopneumonia,  chronic  bronchitis, 
pulmonary  oedema,  and  consumption. 

In  the  majority  of  instances  the  diagnostic  significance  of  the  symp- 
tom cough  is  direct  and  obvious.  It  is  the  indication  of  disease  affecting 
the  respiratory  organs,  manifested  more  or  less  fully  by  concurrent  signs 
and  symptoms;  in  a  far  smaller  proportion  of  cases  its  significance  is 
remote  and  obscure  and  only  to  be  learned  by  close  and  systematic  study 


SYMPTOMS  AND  SIGNS:    EXPECTORATION.  467 

of  the  various  organs  or  parts  to  derangements  of  which  it  may  be  due. 
Important  among  these  derangements  are  diseases  of  the  intrathoracic 
circulatory  organs,  mediastinum,  ears,  teeth,  and  nose,  some  nervous  affec- 
tions, and  the  neurotic  constitution.  To  this  list  must  be  added  malinger- 
ing, since  cough  may  be  a  voluntary  act. 

THE  EXPECTORATION  OR  SPUTUM. 

These  terms  are  applied  to  material  voided  by  coughing  or  hacking. 
The  expectorated  substance  is  usually  a  secretion  or  exudate  derived  from 
the  mucous  membrane  of  the  nose,  pharynx,  larynx,  or  bronchial  tubes,  or 
from  the  alveoli.  It  may  consist  of  pus,  which  finds  its  way  into  the  air- 
passages  from  an  abscess  or  an  empyema,  or  of  blood  from  the  pulmonary 
vessels  or  an  aneurism.  "With  these  substances  are  frequently  admixtures 
of  food,  drink,  and  the  secretions  of  the  mouth.  Macroscopic  and  micro- 
scopic foreign  bodies  which  have  found  their  way  into  the  respiratory 
passages  are  usually  voided  in  the  sputa. 

Any  of  these  substances  may  be  present  and  not  expectorated.  In- 
fants and  young  children  almost  always  swallow  the  sputa  and  older 
persons  frequently  do  so  as  a  habit  or  from  inability  to  expectorate  or  in 
abnormal  mental  states. 

The  naked-eye  examination  of  the  expectorated  matter  is  frequently 
of  great  use  in  diagnosis;  the  microscopic  examination  is. often  essential. 
For  the  ordinary  bed-side  examination  a  considerable  quantity  of  the 
sputum  should  be  collected,  preferably  in  a   transparent   glass  spit-cup. 

The  quantity  of  the  sputum  varies  according  to  the  nature  of  the  path- 
ological process.  Persistent  and  distressing  cough  may  yield  only  an 
occasional  small  tough  mass  of  tenacious  material,  as  in  dry  bronchitis  or 
beginning  phthisis.  In  other  patients  an  occasional  spell  of  coughing 
may  bring  up  enormous  quantities  of  material,  as  in  some  forms  of  chronic 
bronchitis,  bronchiectasis,  advanced  phthisis,  pulmonary  oedema,  and 
haemoptysis.  The  amount  of  pus  expectorated  in  empyema  with  broncho- 
pulmonary fistula  may  exceed  1000  c.c.  in  twenty-four  hours. 

The  consistence  bears  some  relation  to  the  amount.  An  abundant 
expectoration  is  usually  more  fluid  than  a  scanty  one.  Sputum  composed 
of  blood,  pus,  or  a  serous  fluid  is  always  thin;  that  consisting  of  mucus  or 
mucopus  usually  thick  and  frequently  tough  and  tenacious. 

The  reaction  of  fresh  sputum  is  commonly  alkaline.  After  standing 
for  some  hours  in  the  cup,  the  sputum  yields  an  acid  reaction — a  change 
due  to  decomposition  processes  caused  by  bacteria. 

The  color  and  translucency  vary  with  the  nature  of  the  disease. 
Mucous  expectoration  may  be  transparent  and  thin,  resembling  saliva  in 
consistency,  or  much  thicker  and  still  transparent.  In  proportion  as 
cellular  elements  are  present  the  sputum  becomes  thick  and  opaque, 
assuming  the  yellowish  or  greenish-yellow  hue  of  pus.  The  gradations  are 
expressed  by  the  terms  mucous,  mucoid,  mucopurulent,  and  purulent  ex- 
pectoration. Serous  expectoration  is  usually  clear  and  transparent,  some- 
times  slightly   kinged   with    blood.      It    is   thin,   frothy,   and    abundant,   and 

occurs  in  oedema  of  the  lungs  and  in  the  rare  cases  of  perforation  of  a 


468  MEDICAL  DIAGNOSIS. 

serous  pleural  exudate.  The  albuminous  expectoration  which  exception- 
ally follows  the  aspiration  of  a  pleural  exudate  is  also  thin,  colorless,  and 
abundant.  The  color  is  red  when  the  sputum  is  admixed  with  blood. 
The  proportion  varies  from  pure  blood  to  a  mere  trace  sufficient  to  impart 
a  faint  pink  tinge.  Hemorrhagic  sputum  occurs  in  traumatism  of  the 
lungs,  in  the  blood-spitting  of  tuberculosis,  in  pulmonary  infarct,  and  in 
croupous  pneumonia.  It  is  also  present  in  cases  of  gangrene  of  the  lung, 
tumor  of  the  lung,  and  intense  pulmonary  congestion.  The  "rusty 
sputum''  of  pneumonia  owes  its  varying  shades  of  color  to  derivatives  of 
the  blood-coloring  matter.  In  rare  instances  the  sputum  of  pneumonia 
is  lemon-yellow  or  grass-green.  These  variations  suggest  the  changes  in 
color  that  take  place  in  the  subcutaneous  blood  extravasations  following 
a  bruise.  In  the  adynamic  and  septic  forms  of  croupous  pneumonia  and, 
more  rarely,  in  gangrene  of  the  lungs  the  expectoration  is  fluid  and  dark 
colored.  This  form  of  sputum  is  described  as  "prune-juice"  expectoration. 
The  sputum  in  malignant  disease  of  the  lungs  is  often  viscid,  tenacious, 
and  of  a  bright  red  color.  This  is  the  "currant-jelly"  sputum  of  authors. 
A  still  more  objectionable  term  is  "anchovy-sauce"  sputum — a  term 
applied  to  brownish-red  sputum  such  as  is  seen  in  rupture  of  a  liver  abscess 
through  the  lungs,  the  peculiar  appearance  of  which  is  due  to  the  mixture 
of  altered  blood,  pus,  and  bile. 

Blood-streaked  sputum  may  occur  in  the  following  conditions: 
violent  cough,  acute  bronchitis,  or  disease  of  the  mitral  valves.  It  may 
result  from  the  admixture  of  blood  from  the  mouth,  as  in  the  case  of 
scurvy  and  other  forms  of  inflammation  of  the  gums  with  bleeding,  or 
of  ulceration  of  the  tonsils  or  pharynx,  or  from  the  oozing  of  blood  from 
an  aortic  aneurism  into  a  bronchus.  It  occurs  also  in  acute  broncho- 
pneumonia and  plastic  bronchitis.  It  is  very  often  observed  a  day  or  two 
after  an  attack  of  haemoptysis.  Under  these  circumstances  the  streaks  or 
masses  of  blood  are  clotted  and  dark.  Blood-streaked  sputum  is  not 
uncommon  during  the  course  of  pulmonary  phthisis. 

Yellow  or  green  sputa  can  only  be  regarded  as  deriving  their 
color  from  altered  bile  pigment  when  icterus  or  at  least  yellowness  of  the 
conjunctiva  and  biliary  pigment  in  the  urine  are  actually  present.  Icteric 
sputum  may  occur  not  only  in  pneumonia  complicated  with  jaundice  but 
also  in  any  form  of  lung  disease  in  a  patient  suffering  from  jaundice.  A 
peculiar  brownish  tint  is  sometimes  seen  in  the  sputum  in  cases  of  chronic 
valvular  disease.  It  is  due  to  the  presence  of  amorphous  pigment  in  the 
epithelial  cells.  The  brownish  sputum  sometimes  seen  in  pulmonary  abscess 
and  other  destructive  processes  involving  the  lung  owes  its  color  to  the 
presence  of  hsematoidin  crystals,  which  are  also  the  source  of  the  coloring 
matter  in  the  ochre-yellow  purulent  sputum  of  liver  abscess  with  perfor- 
ation into  the  lung.  Greenish  sputum  is  sometimes  encountered  in  sarcoma 
of  the  lungs  and  very  rarely  in  carcinoma.  Remarkable  coloration  follows 
the  habitual  inhalation  of  certain  dust-particles.  Black  sputum  is  common 
in  those  who  breathe  an  atmosphere  laden  with  coal-dust  or  soot.  The 
pigment  particles  are  only  to  a  limited  extent  free  in  the  sputum;  much 
more  commonly  they  are  enclosed  in  round  or  oval  cells  which  are  in  part 
epithelial,  in  part  leucocytes. 


SYMPTOMS  AND  SIGNS:   EXPECTORATION.  469 

The  color  of  the  sputum  varies  in  different  forms  of  pneumonoconiosis. 
In  anthracosis  it  is  often  of  an  intense  black;  in  the  siderosis  of  mirror 
polishers  it  may  be  ochre-red;  workers  in  lapis  lazuli  may  have  a  blue 
sputum,  and  so  on.  The  dust  particles  which  are  expectorated  are  those 
recently  inhaled  which  have  not  yet  penetrated  to  the  lung  parenchyma, 
as  is  shown  by  the  fact  that  the  color  disappears  from  the  sputum  in  the 
course  of  a  short  time  after  the  workman  has  abandoned  his  occupation. 
If  however  the  color  persists  or  returns  after  a  time,  it  is  the  sign  of  a 
destructive  process,  usually  tuberculous.  Various  colors  may  be  imparted 
to  the  sputum  by  articles  of  food  or  drink,  as  milk,  wine,  coffee,  or  medi- 
cines. Finally  after  the  sputum  has  been  ejected  it  may  undergo  color 
changes  in  consequence  of  the  growth  of  chromatogenous  bacteria  and 
thus  become  blue,  green,  yellow,  or  red.  The  Bacillus  pyocyaneus  may 
be  the  cause  of  a  blue  discoloration  of  the  sputum. 

Air. — Air  in  the  sputum  is  shown  by  the  presence  of  minute  bubbles. 
The  quantity  depends  upon  circumstances.  It  is  greater  in  sputum  from 
the  finer  than  in  that  from  the  larger  tubes,  in  sputum  of  thin  than  in  that 
of  thick  and  tenacious  consistency,  and  in  the  sputum  which  is  largely 
composed  of  mucus  than  in  that  which  is  chiefly  pus.  A  little  water  in 
the  spit-cup  enables  us  to  estimate  the  relative  amount  of  air,  as  it  affects 
the  specific  gravity;  sputa  which  float  contain  air;  those  which  sink  do  not. 
The  sputa  of  phthisis  and  bronchitis  often  present  the  appearance  of  flat 
circular  or  coin-shaped  masses — the  so-called  "nummular  sputa" — or  the 
masses  may  be  globular;  they  are  commonly  grayish-white  and  sink  in  water; 
sometimes  they  are  buoyed  up  by  the  small  bubbles  of  air  which  they  contain. 

Stratification. — Layer  formation  takes  place  in  the  collected  sputa 
of  chronic  bronchitis  with  abundant  expectoration — bronchorrhcea — of 
bronchiectasis,  putrid  bronchitis,  and  gangrene  of  the  lungs.  The  material 
is  of  thin  consistence  and  abundant.  As  a  rule  it  collects  in  three  well- 
defined  layers  which  can  be  studied  by  the  use  of  a  glass  spit-cup.  The 
upper  stratum  contains  air  and  is  often  frothy,  the  middle  is  fluid  and 
consists  of  mucus  or  pus-serum,  and  the  lower  is  sedimentary  and  made  up 
of  pus  corpuscles,  molecular  lung  detritus,  and  shreds  of  necrotic  tissue. 

Odor. — The  odor  of  fresh  sputum  has,  under  ordinary  circumstances, 
nothing  characteristic.  Speedy  decomposition  renders  it  offensive.  The 
sputum  of  putrid  bronchitis,  bronchiectasis,  gangrene  of  the  lung,  and 
perforating  empyema  is  always  heavy  and  fetid;  frequently  horribly 
offensive.  In  abscess  of  the  lung  and  in  many  cases  of  advanced  phthisis 
also  it  is  offensive.  The  foulness  is  imparted  to  the  expired  air,  which 
not  infrequently  is  even  more  obnoxious  than  the  sputum.  It  is  probable 
that  in  the  cases  of  pulmonary  consumption  in  which  the  sputum  and 
breath  are  foul  there  is  already  cavity  formation,  though  too  small  in  some 
instances  to  be  recognized  by  the  methods  of  physical  diagnosis,  in  which 
the  secretion  collects  and  undergoes  decomposition.  Very  often  the  odor  is 
imparted  to  the  breath  by  offensive  material  in  the  crypts  of  the  tonsils  or 
by  decaying  teeth  or  other  necrotic  material  in  the  mouth — a  fact  that 
cannot  in  all  cases  be  established  by  the  use  of  deodorizing  mouth  washes, 
since  they  act  only  upon  the  surfaces  with  which  they  come  in  contact 
and  cannot  reach  deeply-seated  tissues  from  which  the  odor  may  proceed. 


470  MEDICAL  DIAGNOSIS. 

Other  Macroscopical  Characters  of  the  Sputum.  —  Very  often  the 
expectorated  material  presents  a  homogeneous  appearance,  as  is  the  case 
with  mucus,  pus,  blood,  etc.  Occasionally,  on  the  other  hand,  the  matter 
expectorated  at  different  times  varies  in  appearance  and  not  infrequently 
a  single  mass  consists  partly  of  mucus  and  partly  of  pus,  or  of  these  sub- 
stances with  masses  of  blood.  The  purulent  expectoration  of  an  empyema 
or  a  pulmonary  abscess  is  sometimes  flaky  or  thready,  best  shown  when 
the  sputum  is  suspended  in  water.  The  naked-eye  characters  of  the  sputum 
may  be  conveniently  studied  by  pouring  a  small  quantity  upon  a  plate  or 
slab  of  which  half  is  black,  the  other  half  white,  or  placing  a  specimen 
between  two  glass  plates  and  examining  it  over  a  white  and  black  back- 
ground alternately.  A  hand  lens  may  be  used  and  particular  objects 
removed  for  microscopical  examination.  Minute,  dirty  gray  masses  of 
necrotic  lung  tissue  containing  elastic  fibres  may  be  detected  in  the  spec- 
imen in  gangrene  and  abscess  of  the  lung  and  in  the  later  stages  of  phthisis; 
fragments  of  necrotic  cartilage  in  destructive  processes  involving  the 
bronchi,  the  trachea,  or  the  larynx,  and  in  rare  cases  shreds  of  tissue  from 
tumors  of  the  bronchi  or  lungs.  Minute,  dirty  white  or  yellowish  masses, 
in  some  instances  constituting  casts  of  the  smaller  bronchial  tubes,  are 
seen  in  fetid  bronchitis  and  gangrene  of  the  lungs.  These  masses  consist 
of  aggregations  of  bacteria  and  crystals  of  the  fatty  acids.  They  have  an 
intensely  disagreeable  odor.  Similar  masses  may  be  expectorated  in  lacu- 
nar tonsillitis  and  are  sometimes  present  in  the  crypts  of  the  tonsils  in 
the  absence  of  inflammation..  Curschmann's  spirals  are  visible  to  the  naked 
eye  and  may  be  studied  with  the  lens.  They  consist  of  twisted  masses 
which  may  reach  1  or  even  2  cm.  in  length  and  have  a  diameter  of  about  1 
mm.  These  masses  are  made  up  of  a  highly  refractive  central  undulating 
core  or  thread  around  which  are  coiled  spiral  filaments  which  are  sometimes 
branching.  The  central  core  was  at  one  time  thought  to  be  fibrinous,  but 
has  more  recently  been  shown  to  consist  of  a  substance  analogous  to  mucin. 
These  spirals  are  formed  in  the  finest  bronchial  tubes  as  the  product  of  an 
exudative  bronchiolitis,  and  as  this  pathological  process  is  frequently 
associated  with  bronchial  asthma  the  spirals  are  very  often  found  in  that 
disease  and  in  well-marked  cases  are  sometimes  present  in  great  numbers. 
The  association,  however,  .is  by  no  means  constant;  cases  of  asthma  are 
occasionally  encountered  in  which  no  spirals,  can  be  found  in  the  sputum, 
and  the  spirals  are  sometimes  present  in  the  expectoration  of  cases  of 
bronchitis  unattended  by  asthmatic  symptoms.  Curschmann's  spirals 
occasionally  appear  also  in  the  sputum  of  croupous  pneumonia  and  are 
then  seen  to  be  in  strong  contrast  with  the  fibrinous  casts  of  the  bronchioles 
which  occur  in  that  disease.  They  have  also  been  encountered  in  the 
sputum  of  pulmonary  phthisis.  Microscopically,  leucocytes,  notably 
eosinophiles,  epithelial  cells,  and  Charcot-Leyden  crystals  are  found  en- 
tangled in  the  spirals. 

Fibrinous  coagula,  recognizable  by  their  white  or  grayish- white  color, 
tough  consistence,  and  characteristic  form,  are  found  in  the  sputum  under 
varying  pathological  conditions.  They  are  usually  coughed  up  in  masses 
surrounded  with  mucus  and,  when  of  great  size,  with  difficulty.  In  diph- 
theria fibrinous  pseudomembrane   is  expectorated,   sometimes   in    irregu- 


SYMPTOMS  AXD  SIGNS:    EXPECTORATION.  471 

lar  masses,  sometimes  as  a  fibrinous  mould,  more  or  less  incomplete,  of  the 
larvnx  or  trachea.  When  the  diphtheritic  exudate  extends  to  the  bronchi, 
branching  casts  are  sometimes  coughed  up.  These  casts  may  be  easily 
recognized  in  the  sputum  and  are  of  great  importance  both  in  diagnosis 
and  prognosis.  Fibrinous  casts  are  common  in  croupous  pneumonia,  in 
the  sputum  of  which  they  are  frequently  present  in  great  numbers.  They 
can  be  readily  seen  when  the  sputum  is  shaken  with  water  in  a  test-tube, 
or  when  the  masses  of  mucus  in  which  they  are  embedded  are  shaken  out 
in  water  with  a  forceps.  In  pneumonic  sputum  the  fibrinous  casts  are 
small.  Similar  casts  consisting  chiefly  of  mucus  are  characteristic  of 
so-called  fibrinous  or  croupous  bronchitis  and  provoke  the  intense  paroxys- 
mal cough  of  that  disease. 

Foreign  bodies  that  have  found  their  way  into  the  air-passages  by 
aspiration  are  usually  expectorated  promptly.  They  may,  however, 
remain  in  a  bronchus  for  a  long  time  and  give  rise  to  symptoms  of  vary- 
ing intensity.  Instances  are  recorded  in  which  a  tooth,  cherry-pits  and  other 
seeds,  a  beard  of  wheat,  etc.,  have  been  expectorated  after  periods  of 
months  or  years.  Bronchial  concretions,  consisting  in  the  main  of  lime 
salts  and  sometimes  of  considerable  size,  are  in  rare  instances  found  in 
the  sputum.  They  occur  only  in  chronic  conditions  and  are  formed  in 
the  cavities  of  phthisis  and  bronchiectasis,  or  consist  of  fragments  of 
bronchial  glands  that  have  undergone  calcareous  degeneration  and  found 
their  way  into  the  bronchial  system.  Even  more  rare  is  the  presence  in 
the  sputum  of  echinococcus  daughter  cysts,  membranes,  or  hooklets, 
which  have  found  their  way  from  the  lung,  pleura,  or  the  liver  into  the 
bronchi. 

The  Sputum  in  Different  Diseases. 

Bronchitis. — The  sputum  is  usually  mucoid  and  mucopurulent.  As  a 
rule,  at  the  beginning  of  an  acute  bronchial  catarrh  the  bronchial  secretion 
is  diminished  and  the  sputum  scanty.  In  the  course  of  some  days,  as  the 
symptoms  ameliorate,  the  expectoration  becomes  more  abundant,  less 
tenacious,  and  distinctly  purulent.  As  the  general  symptoms  improve 
there  is  a  gradual  diminution  in  the  quantity  of  the  sputum.  In  chronic 
bronchitis  the  expectoration  varies  greatly;  sometimes  it  is  more,  some- 
times less  purulent.  The  subjective  sensations  of  the  patient  are  usually 
better  when  the  sputum  is  of  moderate  amount,  worse  when  the  expec- 
toration is  suppressed  or  greatly  increased  in  quantity  (see  bronchitis). 

Fibrinous  or  Croupous  Bronchitis. — The  sputum  differs  from  that  of 
ordinary  bronchitis  in  that  from  time  to  time  it  contains  fibrinous  casts 
associated  with  blood.  Charcot-Leyden  crystals  are  also  present.  The 
expectoration  of  the  larger  casts  very  often  takes  place  after  distressing 
cough,  recurring  in  paroxysms  which  are  separated  by  periods  of  urgent 
dyspnoea. 

Pulmonary  Tuberculosis. — The  sputum  of  tuberculosis  presents  to 
the  naked  eye  nothing  characteristic.  All  varieties  of  sputum  that  occur 
in  ordinary  bronchitis,  from  mucous  to  purulent,  occur  in  phthisis.  In 
advanced  ulcerative  phthisis  purulent  expectoration  is  often  constant  and 
abundant.      For   the    provisional    diagnosis    the    presence    of   the    minute 


472  MEDICAL  DIAGNOSIS. 

grayish  masses  which  frequently  contain  colonies  of  tubercle  bacilli  is 
important.  Very  often  the  sputum  has  an  offensive  odor;  this  is  espe- 
cially the  case  when  there  are  cavities,  the  contents  of  which  undergo 
stagnation  and  decomposition.  A  positive  diagnosis  rests  upon  the  pres- 
ence of  tubercle  bacilli  and,  in  the  absence  of  other  destructive  pulmonary 
lesions,  the  presence  of  elastic  fibres.  It  is  important  for  the  student  to 
bear  in  mind  that  there  is  no  constant  relation  between  the  abundance  of 
these  morphological  elements  and  the  intensity  of  the  process,  therefore 
the  gravity  of  the  prognosis.  There  are  cases  of  pulmonary  tuberculosis 
of  the  gravest  character  in  which  neither  tubercle  bacilli  nor  elastic  fibres 
are  found.  Very  often  these  are  cases  of  phthisis  florida  or  of  disseminated 
miliary  tuberculosis  in  which  the  constitutional  symptoms  develop  in  ad- 
vance of  the  local  manifestations.  The  abundant  catarrhal  secretion,  so 
common  in  unfavorable  cases>  proportionately  diminishes  the  number  of 
tubercle  bacilli  present  in  single  specimens.  On  the  other  hand  tubercle 
bacilli  and  elastic  fibres  are  frequently  found  in  the  early  stages  at  a  period 
when  the  physical  examination  of  the  lung  yields  vague  and  uncertain  signs. 
The  diminution  or  temporary  disappearance  of  tubercle  bacilli  and  elastic 
fibres  from  the  sputum  cannot  be  regarded  as  indicating  a  favorable  prog- 
ress of  the  case  in  the  absence  of  the  general  clinical  indications  of  an  arrest 
of  the  process,  such  as  diminished  cough,  improved  appetite,  gain  in  weight, 
and  disappearance  of  fever.  In  a  suspected  case  the  presence  of  tubercle 
bacilli  in  the  sputum  justifies  a  positive  diagnosis.  Their  absence  cannot 
be  regarded  as  conclusive  until  repeated  examinations  have  been  made. 

Acute  Miliary  Tuberculosis.  —  The  sputum  is  that  of  ordinary 
catarrhal  bronchitis  and  does  not  contain  tubercle  bacilli  except  when 
there  is  an  associated  ulcerative  phthisis.  In  a  large  proportion  of  the 
cases  there  is  no  expectoration. 

Croupous  Pneumonia. — Hemorrhagic  sputum  is  characteristic.  Blood- 
spitting  may  be  the  initial  symptom.  At  first  the  sputum  is  commonly 
mucoid,  transparent  and  homogeneous;  after  twenty-four  hours  it  is 
blood-tinged  and  viscid  so  that  it  adheres  to  the  bottom  of  the  spit-cup 
when  turned  upside  down,  and  sometimes  has  to  be  wiped  from  the  lips 
or  face  of  the  patient.  At  first  red  from  unchanged  blood-coloring  matter 
it  gradually  becomes  rusty  or  orange-yellow  in  color.  Occasionally  the 
sputa  are  variable;  sometimes  mucoid,  sometimes  blood-streaked,  at 
other  times  pure  blood.  When  jaundice  is  present  the  sputum  may  be 
green  or  yellow  from  the  presence  of  bile  pigment.  Very  commonly  the 
sputum  contains  fibrinous  casts  of  the  smaller  tubes.  If  there  is  an  asso- 
ciated bronchitis  of  the  smaller  tubes  the  typical  pneumonic  sputum  may 
be  modified  by  the  presence  of  mucus  or  mucopus.  Fluid  sputum  of  a 
dark  brown  color — the  so-called  "prune-juice"  expectoration  —  is  an 
unfavorable  sign  since  it  may  indicate  a  beginning  oedema  of  the  lungs. 
In  some  instances  a  diminished  consistency  of  the  sputum  marks  the 
beginning  of  resolution.  The  amount  of  sputum  in  croupous  pneumonia 
is  very  variable.  In  children  and  the  aged,  and  in  adynamic  cases,  there 
may  be  none,  and  exceptionally  it  may  be  scanty  in  classical  cases  in  adults. 
A  quantity  amounting  to  200-500  c.c.  in  twenty-four  hours  is  not  uncom- 
mon.   The  amount  after  the  crisis,  abundant  at  first,  gradually  diminishes. 


SYMPTOMS  AND  SIGNS:   EXPECTORATION.  473 

In  some  cases  there  is  at  this  period  little  or  no  expectoration.  Under 
the  microscope  are  seen  leucocytes,  erythrocytes,  mucous  corpuscles,  epi- 
thelial cells,  and  occasionally  haematoidin  crystals.  The  pneumococcus  of 
Weichselbaum  and  Frankel  is  present  in  the  vast  majority  of  cases,  and 
sometimes  Friedlander's  bacillus.  Fibrinous  casts  of  the  bronchioles  and 
moulds  of  the  alveoli  are  not  uncommon.  Chemically  the  expectoration  is 
particularly  rich  in  sodium  chloride. 

Bronchopneumonia,  Including  Aspiration  Pneumonia  and  Hypo- 
static Pneumonia. — The  sputum  usually  presents  the  appearance  of  the 
ordinary  forms  of  bronchitis;  exceptionally  that  of  croupous  pneumonia. 
The  latter  is  intelligible,  since  not  only  in  the  clinical  phenomena  but  also 
in  the  histological  findings  there  are  cases  of  bronchopneumonia  which 
are  difficult  to  distinguish  from  croupous  pneumonia.  In  these  cases  the 
sputum  is  hemorrhagic  and  contains  fibrinous  exudate.  Bacteriologically 
a  mixed  infection  is  the  rule.  The  pneumococcus  and  Friedlander's  bacillus 
are  found  in  association  with  the  ordinary  pus-producing  and  other  organ- 
isms. The  Klebs-Lofrler  bacillus  is  present  when  the  lesions  are  secondary 
to  diphtheria.  In  the  lobular  forms  the  streptococcus  is  the  common 
organism;   in  the  lobar  forms,  the  pneumococcus. 

Gangrene  of  the  Lungs. —The  intensely  offensive  odor,  abundance, 
fluidity,  and  dark,  dirty,  greenish-brown  color  are  characteristic.  Upon 
standing  the  sputum  separates  into  three  strata — an  upper  frothy  layer, 
which  may  contain  necrotic  particles  of  lung  tissue  which  float  by  reason 
of  entangled  air,  a  middle  thin  layer,  and  a  greenish-brown  sediment  which 
consists  in  part  of  leucocytes,  in  part  of  gangrenous  detritus.  Shreddy 
fragments  of  lung  tissue  of  considerable  size  and  frequently  showing  the 
alveolar  arrangement  may  be  picked  out  if  the  sediment  is  spread  upon  a 
glass.  Under  the  microscope  are  seen  elastic  fibres,  pigment  granules, 
crystals  of  the  fatty  acids,  cholesterin,  leucine  and  tyrosine  crystals. 
bacteria,  and  leptothrix.  Altered  blood-corpuscles  are  also  present.  When 
the  fluid  is  retained  in  the  gangrenous  cavity  for  some  time,  the  elastic 
fibres  may  undergo  solution  owing  to  the  action  of  a  peptonizing  ferment. 
The  odor  is  the  more  intense  in  proportion  as  the  communication  between 
the  gangrenous  areas  and  the  bronchi  is  more  free.  Cases  occur  in  which, 
in  the  absence  of  odor  during  life,  circumscribed  areas  of  gangrenous  lung 
have  been  found  upon  post-mortem  examination. 

Abscess  of  the  Lung. — The  sputum  is  essentially  purulent.  It  is 
offensive,  but  less  intensely  so  than  that  of  gangrene.  When  placed  in 
water  it  has  a  thready  or  granular  appearance.  When  the  perforation  is 
small  there  is  an  accompanying  catarrhal  bronchitis  and  the  sputa  are 
mucopurulent.  When,  however,  the  abscess  discharges  abruptly,  a  large 
amount  of  pus  commingled  with  masses  of  necrotic  lung  tissue  and  con- 
taining elastic  fibres  in  abundance  la  discharged.  Microscopically  the  spu- 
tum contains  haematoidin,  cholesterin  and  fat  crystals  and  various  bacteria. 

Perforating  Empyema. — The  sputum  resembles  that  of  pulmonary 
abscess.  It  may  be  at  first  free  from  odor  but  in  the  course  of  a  little  time 
becomes  offensive.  It  is  voided  in  considerable  quantities  at  varying 
intervals.  Elastic  fibres  are  wholly  absent  or  are  present  in  small  numbers. 
Haematoidin  and  other  crystals  and  pyogenic  bacteria  are  present. 


474  •  MEDICAL  DIAGNOSIS. 

Putrid  Bronchitis. — The  expectoration  presents  characteristics  simi- 
lar  to  that  of  perforating  empyema.  It  is  purulent  and  foul-smelling,  but 
does  not  contain  elastic  fibres.  It  is  voided  from  time  to  time  in  moder- 
ate amounts;  not  in  large  bulk  at  intervals  of  some  hours  as  is  the  case  in 
empyema  with  bronchopulmonary  fistula  and  bronchiectasis. 

Bronchiectasis. — In  saccular  bronchiectasis  the  sputum  is  sometimes 
mucopurulent,  sometimes  purulent.  It  is  brought  up  from  time  to  time 
in  severe  paroxysms  and  in  large  quantities — mouthfuls.  These  paroxysms 
may  follow  change  of  posture,  the  cough  reflex  being  excited  by  the  shift- 
ing of  accumulated  secretion  from  the  dilatation  to  the  normal  bronchial 
tube.  A  paroxysm  usually  occurs  in  the  morning.  The  color  of  the  expec- 
torated matter  may  be  gray  or  grayish-brown.  It  is  usually  fluid,  acid- 
smelling,  sometimes  extremely  fetid.  Upon  standing  it  separates  into 
three  layers,  an  upper  consisting  of  brownish  froth,  a  middle  thin  watery 
layer,  and  a  lower,  thick  and  granular.  Microscopically  the  sputum  con- 
sists of  pus  corpuscles,  epithelial  cells,  erythrocytes,  and  large  numbers  of 
crystals  of  the  fatty  acids.  Haematoidin  crystals  are  sometimes  seen.  In 
the  absence  of  bronchial  ulceration,  elastic  fibres  are  not  found,  nor  are 
tubercle  bacilli  present.  Nummular  sputa  are  uncommon.  In  many  cases 
the  sputum  cannot  be  distinguished  from  that  of  a  putrid  bronchitis. 
Hemorrhage  occasionally  occurs. 

CEdema  of  the  Lungs. — The  sputum  is  usually  thin,  frothy,  colorless 
or  slightly  blood-tinged,  and  abundant.  Upon  standing  it  deposits  a 
sediment  consisting  in  part  of  red  blood-corpuscles  and  in  part  of  ele- 
ments characteristic  of  the  antecedent  condition,  as  bronchitis  or  pneu- 
monia. It  is  largely  made  up  of  blood-serum  and  is  therefore  rich  in 
albumin.  In  the  rare  cases  in  which  perforation  of  the  lung  occurs  in 
serofibrinous  pleurisy  the  expectorated  matter  resembles  that  of  pulmonary 
oedema  but  is  richer  in  albumin.  A  very  abundant  sputum,  similar  in 
character,  is  sometimes  expectorated  after  paracentesis  thoracis,  begin- 
ning toward  the  close  of  the  operation — the  expectoration  albumineuse  of 
the  French.  This  serous  sputum  is  the  result  of  an  acute  pulmonary 
oedema  following  the  dilatation  of  the  compressed  lung. 

Bronchopulmonary  Hemorrhage — Haemoptysis. — In  the  blood-spit- 
ting which  follows  traumatism,  the  rupture  of  an  aneurism,  the  lesions 
of  tuberculosis,  or  new  growths  involving  the  lungs  the  sputum  consists 
of  more  or  less  abundant,  bright  red,  frothy  blood.  The  distinction  be- 
tween venous  and  arterial  blood  cannot  be  made,  since  the  dark  blood  of 
the  pulmonary  arteries  becomes  oxygenized  and  frothy  during  its  course 
through  the  bronchial  tubes.  The  differential  diagnosis  between  haemop- 
tysis and  hsematemesis  rests  upon  the  following  facts:  In  bronchopul- 
monary hemorrhage  the  blood  is  coughed  up.  In  gastric  and  oesopha- 
geal hemorrhage  it  is  vomited,  but  the  account  of  the  patient  or  his  friends 
is  not  always  satisfactory;  in  the  excitement  and  alarm  the  distinction 
may  not  be  made.  Moreover  violent  paroxysmal  cough  may  on  the  one 
hand  be  followed  by  gagging  and  vomiting,  while  on  the  other  hand  some 
portion  of  vomited  blood  may  be  drawn  into  the  larynx  by  aspiration 
and  thus  excite  coughing.  The  examination  of  the  blood  itself  is  impor- 
tant.    Bright  red,  frothy  blood  may  usually  be  referred  to  a  lesion  of  the 


SYMPTOMS  AXD  SIGNS:   EXPECTORATIOX.  475 

respiratory  tract;  blood  that  is  dark,  clotted,  and  free  from  air-bubbles, 
to  the  digestive  tract.  But  there  are  exceptions  to  this  rule.  In  profuse 
hemorrhage  from  the  stomach  the  blood  is  sometimes  vomited  so  rapidly 
that  it  is  bright  red  and  fluid,  while  in  abundant  pulmonary  hemorrhage, 
resulting  from  erosions  of  a  large  branch  of  the  pulmonary  artery,  the 
expectorated  blood  may  be  dark  in  color  and  contain  but  little  air. 

The  reaction  of  the  blood  in  haemoptysis  is  alkaline.  In  hsematemesis 
which  occurs  during  digestion,  when  the  stomach  contains  a  large  amount 
of  acid  fluid,  the  reaction  may  be  acid.  Too  great  importance  cannot  be 
ascribed  to  the  reaction  of  the  blood  in  doubtful  cases,  since  vomited 
blood  is  frequently  alkaline.  The  presence  of  particles  of  food  in  the  blood 
is  of  importance  in  diagnosis. 

There  are,  however,  cases  in  which  the  distinction  between  haemoptysis 
and  hsematemesis  cannot  be  immediately  made. 

The  condition  of  the  patient  prior  and  subsequent  to  the  bleeding  is 
in  doubtful  cases  of  greater  importance  than  the  appearance  of  the  blood. 
A  history  of  gastric  symptoms  before  the  blood  loss  or  the  occurrence  of 
such  symptoms  subsequently  is  common  in  bleeding  from  the  stomach. 
The  presence  of  altered  blood  in  the  stools  after  the  hemorrhage  points  to 
bleeding  from  the  stomach  rather  than  from  the  lungs.  On  the  other 
hand  the  mere  fact  that  the  patient  has  suffered  for  some  time  from  cough 
and  expectoration  is  suggestive  of  pulmonary  hemorrhage,  which  is  apt 
to  be  followed  for  some  days  by  the  occasional  expectoration  of  small 
blood-clots  or  of  sputum  mixed  with  blood.  When  due  consideration  is 
given  to  these  facts  errors  of  diagnosis  are  not  likely  to  occur. 

Hemorrhagic  sputum  is  occasionally  encountered  in  acute  bronchitis. 
This  sputum  is  to  be  distinguished  from  pneumonic  sputum  by  the  fact 
that  the  blood  is  present  in  streaks  rather  than  as  a  homogeneous  mixture. 
Profuse  haemoptysis  rarely  has  its  seat  of  origin  in  the  larynx  or  trachea, 
since  the  blood-vessels  of  these'  organs  are  of  relatively  small  size.  On 
the  other  hand,  blood-streaked  sputa  are  not  uncommon  in  acute  catarrhal 
inflammation  of  the  trachea,  larynx,  or  pharynx.  There  are  forms  of 
hemorrhagic  bronchitis  characterized  by  blood-tinged  sputum  which  con- 
tinue for  some  days  or  weeks.  Such  cases  are  not  uncommon  during 
epidemics  of  influenza.  It  sometimes  happens,  especially  during  sleep, 
that  the  blood  in  epistaxis  trickles  into  the  pharynx  and  is  swallowed.  If 
vomited,  such  blood  may  be  regarded  as  due  to  gastric  ulcer.  If  the  blood 
in  the  pharynx  under  these  circumstances  excites  cough  and  is  ejected 
mingled  with  mucus,  it  may  be  erroneously  regarded  as  coming  from  the 
lungs.  If  the  trickling  blood  be  seen  upon  the  wall  of  the  pharynx  the 
diagnosis  is  at  once  established  and  the  precise  site  from  which  it  comes 
may  be  determined  by  means  of  the  rhinoscope. 

Infarcts. — Thesputumin  hemorrhagic  infarct  is  commonly  dark  in  color 
and  resembles  pure  blood,  from  which  it  differs  in  its  somewhat  tenacious 
consistence,  suggestive  of  pneumonic  sputum.  In  point  of  fact  the  sputa 
in  cases  of  pulmonary  infarct  may  vary  according  to  the  amount  of  bron- 
chial secretion  present  from  pure  blood  to  a  tenacious  blood-tinged  mucus. 

Chronic  Valvular  Disease. —  Hemorrhagic  sputum  occurs  in  certain 
cases  of  valvular  disease  of  the  heart,  particularly  in  mitral  stenosis. 


476  MEDICAL  DIAGNOSIS. 


VI. 

CIRCULATION;    PULSATION;    RADIAL   PULSE;    ANOMALIES   OF 
THE  PULSE;    CAPILLARY  PULSE;   VENOUS  PULSE. 

CIRCULATION. 

The  term  arterial  pulse  is  used  to  designate  the  rhythmical  fluctua- 
tions of  the  arterial  pressure  which  correspond  to  the  contractions  of 
the  ventricles  of  the  heart.  These  rhythmic  fluctuations  depend  upon 
the  intermittent  injection  of  blood  from  the  ventricle  to  the  aorta, 
upon  the  resistance  to  the  arterial  flow  produced  by  friction,  and  upon 
the  elasticity  of  the  walls  of  the  arteries.  After  the  blood  enters  the  capil- 
laries the  pressure  is  no  longer  intermittent,  but  is  continuous,  and  pulsa- 
tion under  normal  conditions  disappears.  The  pulse  may  be  affected 
by  changes  either  in  the  force  of  the  ventricular  contractions,  in  the 
elasticity  of  the  arteries,  or  in  the  peripheral  resistance,  and  by  vary- 
ing combinations  of  these  modifications.  The  examination  of  the  arterial 
pulse  is  therefore  obviously  of  great  diagnostic  importance.  By  this 
means  conclusions  may  be  reached  in  regard  to  a  wide  range  of  clinical 
facts,  including  the  innervation  of  the  heart,  the  power  of  the  heart  muscle, 
the  blood-pressure,  the  blood  loss  in  hemorrhage  and  anaemia  due  to  other 
causes,  the  condition  of  the  peripheral  arteries,  the  action  of  fever-pro- 
ducing toxins  upon  the  heart  and  blood-vessels,  and  finally,  under  certain 
conditions,  in  regard  to  the  presence  and  nature  of  valvular  lesions. 

PULSATION. 

Arterial  pulsation  may  be  studied  in  any  of  the  superficial  arteries. 
The  methods  employed  in  ordinary  clinical  work  are  palpation  and  inspec- 
tion. Auscultation  is  of  more  limited  application  in  the  study  of  the  blood- 
vessels. The  results  obtained  by  the  use  of  the  sphygmograph  are  of 
more  value  in  clinical  research  and  for.  purposes  of  record  and  comparison 
than  for  diagnosis. 

The  increase  in  the  contents  of  the  arterial  system  which  causes  the 
pulsation  is  accompanied  not  only  by  an  increase  in  the  tension  of  the 
artery  at  any  given  point  but  also  by  an  increase  in  the  length  of  the  vessel. 
This  increase  in  length  results  in  a  more  or  less  marked  lateral  undulation 
and  exaggeration  of  the  curves  of  the  vessel,  normally  not  sufficient  to 
attract  attention,  but  conspicuous  in  the  temporal  arteries  of  emaciated 
persons  and  at  various  points  in  the  course  of  the  superficial  arteries  in 
conditions,  such  as  aortic  insufficiency,  which  are  attended  with  cardiac 
hypertrophy  and  relaxation  of  the  arterial  walls.  The  arterial  pulse, 
corresponding  to  a  contraction  of  the  ventricles,  is  not  perceptible  at 
the  same  moment  at  all  parts  of  the  body,  an  appreciable  interval  sepa- 
rating the  cardiac  impulse,  the  radial  pulse,  and  that  of  the  dorsal  artery 
of  the  foot. 


SYMPTOMS  AND  SIGNS:   PULSATION.  477 

The  Aorta  axd  Its  Branches. — Pulsation  in  the  notch  of  the  ster- 
num is  occasionally  seen  in  aged  persons  in  the  absence  of  disease.  It 
occurs  in  dilatation  of  the  aorta  and  is  a  sign  of  aneurism  of  the  trans- 
verse portion  of  the  arch.  In  rare  cases  it  is  due  to  an  anomalous  distri- 
bution of  the  branches  of  the  aorta  in  this  region. 

Pulsation  at  the  root  of  the  xeck  is  common  in  cardiac  hyper- 
trophy and  dilatation,  in  aortic  insufficiency,  and  in  neurotic  and  anaemic 
conditions,  especially  during  periods  of  physical  or  mental  excitement. 
It  is  a  prominent  symptom  of  exophthalmic  goitre.  Under  these  circum- 
stances pulsation  of  the  aorta  is  associated  with  a  heaving  impulse  in  the 
innominate  and  carotids,  communicated  to  the  overlying  tissues,  so  that 
throbbing  in  this  region  becomes  a  sign  of  importance.  It  is  often  accom- 
panied with  distention  of  the  veins  and  flushing  of  the  face. 

The  differential  diagnosis  between  dynamic  dilatation  of  the  arch  of 
the  aorta  and  aneurism  cannot  in  all  cases  be  made  during  life.  Not  rarely 
when  the  signs  of  dilatation  of  the  arch  and  enlargement  of  the  innominate 
and  right  carotid  have  been  well  marked  clinically,  the  vessels  have  been 
found  post  mortem  to  be  of  normal  measurement. 

Pulsatiox  of  the  subclaviaxs  occurs  in  the  general  pulsation  at 
the  root  of  the  neck,  above  spoken  of.  It  is  usually  less  marked  than  that 
of  the  innominate  and  carotids.  Visible  pulsation  of  the  subclavians 
is  sometimes  present  in  consolidation  and  retraction  of  the  lung  in 
phthisis. 

Pulsatiox  of  the  abdomixal  aorta  is  very  common.  It  may  often 
be  made  out  in  quite  thin  persons  under  normal  conditions  both  by  inspec- 
tion and  palpation.  Under  these  circumstances  it  is  of  very  slight  inten- 
sity. More  vigorous  pulsation  in  the  line  of  the  abdominal  aorta,  namely, 
in  the  median  line  or  slightly  to  the  left  of  it,  and  in  the  epigastric  zone 
is  an  important  sign  of  disease.  Objectively  the  pulsation  varies  in  degree. 
It  is  frequently  violent  and  throbbing  and  may  be  demonstrated  by  the 
motion  communicated  to  the  stethoscope  lightly  pressed  upon  the  surface. 
Subjectively  the  sensation  of  throbbing  is  annoying  and  frequently  dis- 
tressing. It  often  prevents  sleep.  Epigastric  pulsation  is  not  in  all  in- 
stances due  to  the  movements  of  the  aorta.  It  may  be  directly  due  to  the 
heart.  A  faint  pulsation  in  the  region  of  the  ensiform  cartilage  occurs  in 
physiological  over-actioD  of  the  heart,  in  hypertrophy  and  dilatation  of 
the  right  vent  tide,  and  in  displacement  of  the  heart  towards  the  right  in 
(  "iisequence  of  left-sided  pleural  effusion  or  of  emphysema.  In  the  last 
named  condition  the  epigastric  pulsation  is  often  marked,  since  the  heart 
is  displaced  toward  the  median  line  and  the  right  ventricle  is  hypertro- 
phied.  The  pulsation  is  transmitted  to  the  left  lobe  of  the  liver.  It  is 
more  marked  in  the  neighborhood  of  the  ensiform  appendix  and  costal 
cartilages  than  toward  the  umbilicus,  and  nice  observation  will  show 
that  it  corresponds  in  time  to  the  cardiac  systole,  whereas  aortic  pulsation 
is  slightly  post-systolic. 

•  The  mosl  common  causes  of  pulsation  of  the  abdominal  aorta  are 
referable  to  the  nervous  system— simple  dynamic  pulsation.  The  throb- 
bing may  Ik-  a  direct  manifestation  of  neurasthenia  or  hysteria,  or  it  may 
be  a  reflex  manifestation  of  disorders  of  the  gastro-intestinal  tract.     It  is 


478  MEDICAL  DIAGNOSIS. 

much  more  common  in  females  and  in  early  life.  It  occurs  also  as  the 
result  of  diminution  of  the  amount  of  blood  and  thus  becomes  one  of  the 
signs  of  anaemia  due  to  hemorrhage  or  other  cause.  Marked  epigastric 
pulsation  frequently  occurs  as  a  sign  of  enlarged  lymphatic  glands,  carci- 
noma of  the  stomach  or  pancreas,  or  other  form  of  tumor  overlying  the 
aorta.  In  rare  instances  fecal  accumulations  in  the  colon  transmit  the 
aortic  impulse  to  the  surface.  Thorough  evacuation  of  the  bowels  is  an 
imperative  preliminary  measure  in  the  diagnosis  of  doubtful  cases.  Finally 
it  may  be  due  to  an  aneurism. 

The  diagnostic  significance  of  this  sign  varies  greatly  and  in  some 
cases  is  only  to  be  determined  by  careful  study  of  the  associated  clinical 
phenomena.  In  simple  dynamic  pulsation  the  aorta  may  in  thin  persons 
frequently  be  felt  to  be  somewhat  dilated,  especially  during  the  paroxysm, 
but  no  distinct  tumor  formation  can  be  recognized.  The  symptoms  of 
neurasthenia  or  the  stigmata  of  hysteria  are  present  and  these  are  often 
associated  with  gastro-intestinal  symptoms.  The  throbbing  is  intense  and 
distressing,  sometimes  diffused  but  never  distinctly  expansive.  It  can 
be  felt  when  the  patient  is  in  the  knee-elbow  posture.  The  throbbing  of 
anaemia  is  much  less  marked.  Pulsation  transmitted  from  the  aorta  through 
an  overlying  tumor  communicates  a  lifting  sensation  to  the  hand  upon 
palpation,  is  usually  circumscribed,  not  expansile,  and  disappears  when 
the  patient  is  examined  in  the  knee-elbow  position,  the  mass  falling  away 
from  the  aorta  under  the  action  of  gravity.  The  clinical  phenomena  of 
the  primary  condition  are  usually  more  or  less  well  defined.  Errors  of 
diagnosis  not  infrequently  occur  under  these  circumstances,  the  tumor 
being  mistaken  for  an  aneurism.  When  well  defined  the  pulsation  of 
an  abdominal  aneurism  is  characteristic.  If  the  aneurism  be  of  large  size 
there  is  dulness  continuous  with  that  of  the  left  lobe  of  the  liver.  In  thin 
persons  a  distinct  tumor  may  be  felt,  the  pulsation  is  expansile  and 
forcible,  and  persistent  rather  than  paroxysmal.  A  systolic  murmur  is 
very  commonly  heard  in  the  absence  of  pressure  of  the  stethoscope  or  the 
murmur  may  be  audible  in  the  back.  In  some  cases  a  low-pitched  soft 
diastolic  murmur  is  heard.  In  many  cases  there  is  a  distinct  systolic  thrill. 
Both  the  murmur  and  thrill  may  occur  in  other  conditions  which  cause  an 
abrupt  narrowing  in  the  lumen  of  the  aorta,  and  may  be  produced  by  the 
pressure  of  the  stethoscope.  These  signs  are  occasionally  encountered 
in  the  epigastric  pulsation  of  nervous  diseases  and  in  tumors  of  various 
kinds  developing  in  relation  with  the  abdominal  aorta.  The  diagnosis  of 
aneurism  must  therefore  be  made  with  extreme  caution.  It  is  justified 
in  cases  in  which  there  is  a  distinct  tumor  with  expansile  pulsation  per- 
sisting in  the  knee-elbow  posture  and  when  radiating  pain,  vomiting,  and 
retardation  of  the  femoral  pulse  are  present.  The  pulsation  of  an  abdom- 
inal aneurism  may  be  manifest  in  the  left  hypochondrium  or  lumbar 
region.  The  X-rays  furnish  an  important  aid  to  diagnosis  in  doubtful 
cases.  Epigastric  pulsation  must  not  be  confounded  with  the  purely 
subjective  sensation  of  fluttering  in  the  left  hypochondrium  of  which 
hysterical  women  frequently  complain.  These  two  phenomena  are  en- 
tirely distinct,  though  they  are  frequently  present  in  the  same  case. 


SYMPTOMS  AND  SIGNS:    RADIAL  PULSE.  479 

RADIAL   PULSE. 

The  pulse  may  be  studied  in  any  superficial  artery.  For  this  purpose 
the  radial,  because  of  its  accessibility  and  convenience,  is  usually  selected. 
This  artery  is  palpated  over  the  flat  portion  of  the  radius  between  the 
styloid  process  and  the  tendon  of  the  radialis  internus.  In  an  anomalous 
distribution  of  the  artery  the  radial  pulse  must  be  sought  for  elsewhere. 
It  is  a  good  plan  to  compare  the  pulse  in  the  radials  of  both  sides.  It 
occasionally  occurs  that  a  small  arterial  twig  occupies  the  usual  position 
of  the  radial  while  the  main  branch  has  an  anomalous  course.  In  the 
absence  of  comparison  with  the  other  side  an  erroneous  conclusion  as  to 
the  volume  and  force  of  the  pulse  would  be  formed.  In  any  case  of  doubt 
the  pulse  in  the  bend  of  the  elbows  or  in  the  brachial  or  axillary  arteries 
upon  the  two  sides  may  be  compared.  Pathological  differences  in  volume, 
force,  and  time,  that  is  to  say,  retardation  upon  one  side;  are  due  to  the 
interference  with  the  flow  of  blood  in  the  artery  caused  by  endarteritis 
and  aneurism,  or  the  pressure  of  a  tumor  upon  the  wall  of  the  vessel.  Com- 
plete obliteration  results  from  embolism  or  thrombosis.  In  traumatism 
from  extensive  crushing  or  laceration  it  is  a  sign  of  destruction  of  the 
artery.  Retardation  of  the  femoral  pulse  upon  both  sides  may  occur  in 
aneurism  of  the  thoracic  or  abdominal  aorta.  On  one  side  it  is  commonly 
the  sign  of  aneurism  of  the  common  iliac  artery.  Under  certain  circum- 
stances it  is  convenient  to  study  the  pulse  in  the  temporals,  carotids,  or 
even  in  the  posterior  tibials. 

The  best  method  of  feeling  the  pulse  consists  in  the  application  of 
the  tips  of  three  adjacent  fingers,  that  of  the  index  finger  being,  according 
to  an  old  rule,  nearest  the  heart  of  the  patient.  Under  changing  pressure 
the  distention  of  the  artery  which  constitutes  the  pulse  is  recognized  and 
studied.  The  value  of  the  pulse  in  diagnosis  depends  largely  upon  the 
experience  and  judgment  of  the  physician.  In  the  study  of  the  pulse  the 
following  points  require  especial  consideration;  (a)  condition  of  the  arterial 
wall;  (b)  frequency;  (c)  rhythm;  (d)  volume;  (e)  celerity;  (f)  tension;  (g) 
dicrotism. 

The  condition  of  the  arterial  wall  enables  us  to  form  conclusions  as 
to  the  presence  or  absence  of  general  arteriosclerosis,  and  to  recognize 
the  modifications  of  the  pulse-wave  caused  by  changes  in  the  elasticity  of 
the  artery.  It  is  of  much  greater  diagnostic  importance  than  the  pulse- 
rate.  Empty  the  artery  by  pressure  and  roll  it  to  and  fro  upon  the  under- 
lying bone.  In  healthy  individuals  in  early  life  the  artery  is  felt  as  a  strand 
of  soft  elastic  tissue.  In  arteriosclerosis  and  in  those  conditions  in  which 
the  blood-pressure  is  habitually  high,  such  as  chronic  nephritis,  gout,  and 
lead  poisoning,  the  increased  resistance  of  the  artery  may  be  readily  recog- 
nized. It  feels  like  a  whip-cord  under  the  fingers.  In  advanced  arterio- 
sclerosis calcareous  deposits  in  the  wall  of  the  artery — atheroma — can  be 
distinctly  felt,  and  in  some  cases  these  deposits  are  so  coarse  and  irregular 
as  to  warrant  their  comparison  with. a  string  of  wampum.  Such  arteries 
are  often  tortuous.  These  changes  can  be  best  recognized  by  passing  the 
palpating  finger  gently  along  the  course  of  the  artery.  Important  as  is 
the  study  of  the  condition  of  the  walls  of  the  peripheral  arteries  for  the 


480  MEDICAL  DIAGNOSIS. 

diagnosis  of  arteriosclerosis,  it  is  nevertheless  necessary  to  call  attention 
to  the  fact  that  there  are  cases  of  very  advanced  sclerosis  of  the  aorta  and 
even  of  the  coronaries,  and  indeed  of  other  deeply  situated  vessels,  in 
which  the  superficial  arteries  upon  palpation  yield  no  indication  of  changes 
in  their  walls.  To  arteriosclerosis,  which  is  often  unequally  distributed, 
the  radial  shows  no  special  liability.  It  is  therefore  necessary  in  suspected 
cases  to  examine  carefully  the  superficial  arteries  in  various  parts  of  the 
body.  Increased  arterial  tension  and  an  accentuated  aortic  second  sound 
are  important  signs  of  arteriosclerosis. 

Frequency  of  the  Pulse. — By  this  term  is  indicated  the  number  of 
beats  in  a  minute.  It  is  convenient  to  count  the  radial  pulse  for  15  seconds 
and  multiply  the  result  by  4.  If  the  pulse  is  irregular  or  extremely  rapid  it 
becomes  necessary  to  count  for  an  entire  minute  and  to  repeat  the  counting 
in  order  to  avoid  error.  If  after  repeated  observation  wide  variations  in 
the  frequency  are  found,  the  extremes  may  be  recorded.  Various  devices 
have  been  suggested  for  the  counting  of  very  rapid  pulses.  If  regular, 
every  second  or  third  beat  may  be  counted  and  the  result  multiplied  re- 
spectively by  2  or  3;  or  a  dot  for  each  beat  may  be  made  with  a  pencil 
upon  a  sheet  of  paper.  These  methods  are  liable  to  error,  and  variations 
in  the  pulse-frequency  uncountable  by  ordinary  methods,  that  is,  exceeding 
200,  are  without  clinical  importance. 

The  pulse-frequency  is  modified  by  a  great  variety  of  physiological 
influences.  The  pulse  should  therefore  be  counted  regularly  under  simi- 
lar conditions.  When  this  is  impracticable  any  circumstance  liable  to 
influence  the  frequency  should  be  noted. 

Mental  excitement  in  nervous  individuals  exerts  a  marked  influence 
upon  the  frequency  of  the  pulse.  The  approach  of  the  physician  to  the 
bedside  or  the  entrance  of  the  patient  to  the  consulting  room  is  often 
followed  immediately  by  a  rapid  increase.  It  is  therefore  wise  to  post- 
pone the  taking  of  the  pulse  until  after  some  general  conversation  suffi- 
ciently prolonged  to  enable  the  patient  to  regain  his  equanimity. 

The  effect  of  muscular  effort  in  increasing  the  pulse-frequency  is  well 
known.  Athletic  sports,  running,  boxing,  stair-climbing,  and  similar 
effort  may  be  followed  by  a  very  rapid  pulse-rate  which  is  nevertheless 
physiological.  During  convalescence  from  disease  and  in  feeble  and  deli- 
cate persons  slight  movements  of  the  body  increase  the  pulse-frequency, 
which  falls  again  after  a  period  of  rest.  If,  however,  the  effort  be  pro- 
longed the  return  to  the  normal  frequency  is  delayed. 

The  pulse-rate  is  modified  by  the  posture  of  the  body.  It  rises  imme- 
diately upon  change  from  the  recumbent  to  the  sitting  and  again  from  the 
sitting  to  the  standing  position.  The  frequency  attained  immediately  after 
these  changes  falls  again  in  a  little  time  but  not  to  the  normal  of  the  previous 
posture.  The  pulse-rate  for  the  same  individual  is  relatively  higher  while 
each  of  these  positions  is  maintained.  The  figures  in  healthy  individuals,  in 
the  absence  of  other  modifying  conditions,  are  approximately  in  the  recum- 
bent posture  66,  in  the  sitting  70,  in  the  standing  80  beats  per  minute. 

The  pulse-frequency  is  increased  during  the  digestion  of  food.  Hearty 
meals  and  alcoholic  beverages  render  the  increase  more  marked.  The 
diurnal  modifications  of  the  pulse  bear  a  definite  relation  to  the  periods 


SYMPTOMS  AND  SIGNS  :    RADIAL  PULSE.  481 

of  taking  food.  They  occur,  however,  in  those  who  are  fasting  and  bear 
some  relation  to  the  diurnal  variations  of  the  temperature.  The  pulse's 
frequency  is  to  some  extent  modified  by  respiration,  being  slightly  in- 
creased upon  inspiration  and  diminished  upon  expiration.  It  is  higher 
after  paroxysms  of  cough.    It  varies  greatly  at  different  periods  of  life. 

Pulse-frequency  at  Different  Ages. — Rollet. 

At  birth 144-133  per  minute 

To  end  of  1st  year 143-123  per  minute 

10th  to  15th  year 91-  76  per  minute 

20th  to  60th  year 73-  69  per  minute 

Pulse-frequency  in  Childhood. — Vierordt. 

0-  1  year 134      per  minute 

1-  2  years  . 110.6  per  minute 

2-  3  years 108      per  minute 

3-  4  years 108       per  minute 

4-  5  years 103      per  minute 

5-  6  years 98       per  minute 

6-  7  years 92 . 1  per  minute 

7-  8  years 94 .9  per  minute 

8-  9  years 88. 8  per  minute 

9-10  years 91 .8  per  minute 

10-11  years 87.9  per  minute 

1 1-12  years 89. 7  per  minute 

12-13  years 87.9  per  minute 

13-14  years 86. 8  per  minute 

In  general  terms  the  frequency  declines  with  advancing  years.  The 
pulse  in  women  is  about  7  beats  per  minute  more  rapid  than  in  men  of 
corresponding  age.  In  large  individuals  it  is  slightly  slower  under  similar 
conditions  than  in  those  of  smaller  size. 

Cases  are  occasionally  observed  in  which  the  radial  pulse  is  less  fre- 
quent than  the  impulse  of  the  heart.  This  discrepancy  arises  in  conse- 
quence of  the  feebleness  of  certain  contractions  of  the  heart,  the  pulse- 
wave  not  reaching  the  radials.  Under  these  circumstances  the  pulse 
is  commonly  but  not  always  irregular.  In  every  case  of  irregularity  of 
the  pulse  it  is  desirable  to  count  the  contractions  of  the  heart  as  mani- 
fested in  the  precordial  impulse. 

In  general,  departures  from  the  normal  pulse-rate,  either  in  the  direc- 
tion of  increased  or  diminished  frequency,  arise  in  consequence  of  derange- 
ment of  the  nervous  mechanism  of  the  circulation.  Increase  may  be  due 
to  paresis  of  the  pneumogastric  or  irritation  of  the  sympathetic  nerves 
or  the  intracardiac  ganglia;  decrease  to  irritation  of  the  pneumogastric  or 
paresis  of  the  cardiac  sympathetic  nerves  and  ganglia.  Derangements  of 
the  pulse-rate  arise  in  consequence  of  causes  affecting  the  myocardium 
itself. 

Increased  Frequency- Rapid  Heart. —  Perhaps  the  most  common  cause 
of  an  increase  in  the  pulse-rate  is  the  action  of  the  fever-producing 
toxins.  We  find  it  therefore  in  the  febrile  infections,  the  increase  in  the 
pulse-frequency  bearing  a  general  relation  to  the  elevation  of  the  tem- 
perature. The  prognosis  in  severe  febrile  disease  is  more  favorable  where 
this  parallelism  is  maintained  than  in  those  cases  in  which  the  pulse-rate 
is  increased  out  of  proportion  to  the  rise  of  temperature;    the  very  rapid 

31 


482  MEDICAL  DIAGNOSIS. 

pulse  being  the  sign  of  special  implication  of  the  heart  or  vasomotor  sys- 
tem. In  the  acute  febrile  diseases  a  pulse-rate  of  140-160  in  the  adult, 
if  maintained  for  any  length  of  time,  is  of  itself  ominous.  In  children 
even  higher  pulse-rates  are  not  uncommon  in  cases  that  run  a  favorable 
course.  The  effect  of  the  specific  toxins  upon  the  mechanism  of  the 
circulation  is  by  no  means  constant.  A  knowledge  of  the  variations  is  of 
diagnostic  importance  in  doubtful  cases.  In  scarlet  fever  the  pulse-rate  is 
high — 120-160 — throughout  the  whole  course  of  the  attack;  in  diseases 
to  which  it  bears  some  resemblance,  such  as  angina  tonsillaris,  diphtheria, 
rubella,  and  measles,  the  pulse-rate  of  the  period  of  invasion  is  slower.  The 
pulse-rate  in  acute  miliary  tuberculosis  and  in  septicopyemic  conditions 
is  high,  out  of  proportion  to  the  temperature.  In  malignant  endocarditis 
the  pulse  is  rapid  both  during  the  febrile  paroxysms  and  in  their  intervals. 
In  puerperal  sepsis  a  high  pulse-rate  is  more  constant  than  elevation  of 
temperature.  Increased  pulse-frequency  is  common  in  the  early  stages  of 
phthisis  and  usually  persists  throughout  the  whole  course  of  the  disease, 
alike  in  afebrile  periods  and  when  the  temperature  is  moderate  or  excessive. 

On  the  other  hand  the  pulse-frequency  of  enteric  fever  is  low  in  pro- 
portion to  the  temperature.  In  cases  of  average  severity  it  frequently 
does  not  exceed  100-110  with  a  temperature  range  during  the  fastigium 
of  102°  F.  (38.9°  C.)  a.m.  to  104°  F.  (40°  C.)  p.m.  This  fact  is  not  without 
importance  in  the  differential  diagnosis  between  enteric  fever  and  septic 
infections,  the  so-called  typhoid  form  of  malignant  endocarditis  and  acute 
miliary  tuberculosis.  A  very  rapid  pulse  in  enteric  fever  is  usually  the 
sign  of  an  inflammatory  complication  or  secondary  infection. 

A  frequent  pulse  occurs  in  acute  affections  of  the  heart,  endocarditis, 
pericarditis,  and  myocarditis,  and  in  chronic  valvular  disease  in  the  stage 
of  failure  of  compensation.  Increased  pulse-frequency  after  slight  exer- 
tion occurs  in  most  forms  of  chronic  myocarditis,  in  general  muscular 
asthenia,  in  anaemia,  during  convalescence  from  acute  diseases,  and  in  con- 
ditions of  the  neighboring  organs  which  subject  the  heart  to  abnormal 
pressure,  as  pleural  effusion,  thoracic  aneurism,  massive  enlargement  of 
the  liver  and  spleen,  tympany,  and  ascites.  The  frequency  of  the  pulse  is 
increased  in  cardiac  palpitation  from  any  cause. 

The  pulse-frequency , is  greatly  increased  in  many  nervous  diseases. 
A  rapid  pulse  with  subnormal  temperature  is  characteristic  of  shock  and 
collapse.  Acceleration  of  the  pulse  is  a  constant  symptom  of  exophthal- 
mic goitre;  during  the  paroxysms  of  palpitation  the  pulse  is  often  un- 
countable. In  neurasthenia,  Addison's  disease,  the  primary  and  secondary 
anaemias,  arthritis  deformans,  and  locomotor  ataxia  the  pulse-frequency  is 
likewise  habitually  increased.  In  these  conditions  the  rapidity  of  the  pulse 
may  be  continuous  or  show  itself  only  after  moderate  exertion.  In  general 
terms  it  is  proportionate  to  the  severity  of  the  disease.  Pain  often  causes 
increase  in  the  pulse-rate.  Exceptionally  slowness  of  the  pulse  occurs  in 
connection  with  very  intense  pain.    In  either  case  the  derangement  is  reflex. 

Excesses  in  alcohol,  tobacco,  coffee  and  tea,  disorders  of  digestion, 
lack  of  sleep,  other  exhausting  influences,  and  lowered  blood-pressure 
not  rarely  produce  abnormal  pulse-frequency.  Certain  drugs,  as  atro- 
pine, have  the  same  effect. 


SYMPTOMS  AND  SIGNS  :    RADIAL  PULSE.  483 

Tachycardia — Pycnocardia — Heart  Hurry. — The  extreme  rapidity  which 
follows  violent  exercise  or  fright  ma}'  persist  for  days  or  weeks;  the 
rate  may  reach  160-220.  The  condition  may  occur  as  a  pure  neurosis. 
Palpitation  and  dyspnoea  are  not  always  present.  The  patient  is  often 
able  to  attend  to  his  ordinary  duties.  Tachycardia  is  one  of  the  symp- 
toms of  the  neurasthenic  at  the  menopause  and  has  been  attributed  to 
reflex  irritation  from  ovarian  or  uterine  disease.  This  symptom  may  be 
due  to  lesions  such  as  a  tumor  or  clot  in  or  about  the  medulla  or  pressure 
upon  the  pneumogastrics. 

Paroxysmal  tachycardia  is  a  neurosis  characterized  by  attacks  of 
greatly  increased  action  of  the  heart  occurring  at  irregular  intervals  and 
without  obvious  cause.  The  attacks  usually  begin  abruptly  and  are  of 
varying  duration,  frequently  not  exceeding  an  hour  or  two.  The  pulse- 
rate  exceeds  200  and  is  sometimes  uncountable.  Subjective  symptoms 
may  be  absent.    In  many  of  the  cases  there  is  much  distress  and  oppression. 

Diminished  Frequency — Slow  Heart. — In  many  cases  the  normal  pulse- 
rate  does  not  exceed  60.  In  some  individuals  the  pulse  may  be  slow 
under  conditions  in  which  in  others  it  is  rapid.  This  is  often  the  case 
during  the  period  of  convalescence  from  pneumonia,  enteric  fever,  rheu- 
matic fever,  and  diphtheria.  The  pulse  is  slow  while  the  patient  is  at  rest 
but  is  accelerated  by  slight  exertion.  It  is  the  slow  pulse  of  exhaustion 
and  occurs  in  young  persons  and  at  the  close  of  uncomplicated  cases.  Tran- 
sient slowing  of  the  pulse  is  a  postcritical  symptom  in  certain  febrile 
diseases,  as  pneumonia.  If  the  pulse-frequency  remains  high  during  an 
abrupt  fall  of  temperature  in  the  course  of  croupous  pneumonia,  pseudo- 
crisis  is  to  be  thought  of.  Slow  pulse  is  encountered  in  chronic  gastritis 
and  ulcer  and  cancer  of  the  stomach.  It  occurs  in  emphysema  but  is  not 
common  in  other  affections  of  the  respiratory  system.  It  is  not  rare  in 
aortic  stenosis  but  is  infrequent  in  other  valvular  diseases  of  the  heart. 
It  is  an  occasional  but  by  no  means  constant  symptom  in  chronic  myocar- 
ditis. Toxic  agents,  as  lead,  alcohol,  tobacco,  coffee,  digitalis,  and  opium, 
produce  slowing  of  the  pulse,  and  it  occurs  in  some  cases  of  primary  and 
secondary  anaemia,  diabetes,  and  myxcedema,  especially  while  the  patient 
is  at  rest. 

Bradycardia— Brachycardia. — The  pulse-rate  falls  as  low  as  40  and 
may  be  persistently  slow.  It  is  important  to  see  that  the  arterial  pulse 
corresponds  in  frequency  with  the  cardiac  contractions.  Bradycardia 
may  be  physiological  or  pathological.  In  rare  instances  it  is  a  peculiarity 
of  normal  individuals.  During  labor,  whether  premature  or  at  term,  the 
pulse  may  fall  to  40  or  below  it.  Slow  pulse  is  one  of  the  symptoms  of 
hunger  and  exhaustion.  Cachectic  individuals  have  usually  not  only 
subnormal  temperature  but  also  a  slow  pulse-rate.  Slowing  of  the  pulse 
occurs  in  gall-stone  colic,  in  renal  and  hepatic  colic,  and  in  lead  colic.  It  is 
associated  with  acute  but  not  necessarily  with  chronic  jaundice.  Either  the 
circulatory  mechanism  becomes  habituated  to  the  bile  intoxication  or 
the  bile  salts  arc  diminished  in  amount.  Bradycardia  occasionally  occurs 
in  disease  of  the  genito-urinary  tract,  especially  in  nephritis  and  in  unrmia. 
It  is  of  special  diagnostic  importance  in  acute  cerebral  disease  associated 
with    intracranial    pressure.      It   occurs   in    various    forms   of    meningitis, 


484  MEDICAL  DIAGNOSIS. 

especially  tuberculous  meningitis,  in  which  considerable  elevation  of  tem- 
perature is  sometimes  associated  with  a  slow  pulse.  Chronic  cerebral 
compression,  such  as  results  from  tumor  or  hydrocephalus,  is  not  attended 
with  bradycardia  except  during  acute  exacerbations.  Apoplexy,  the 
postepileptic  state,  disease  of  the  medulla  and  diseases  and  injuries  of  the 
cervical  cord  may  be  associated  with  a  very  slow  pulse.  Bradycardia 
occurs  in  general  paresis,  mania,  and  melancholia.  It  constitutes  the 
essential  sign  of  heart  block.  A  very  slow  pulse  is  occasionally  associated 
with  shock  and  may  follow  the  rapid  evacuation  of  large  peritoneal  or 
pleuritic  effusion. 

Rhythm. — Under  normal  conditions  the  pulse  is  regular  or  rhythmic, 
that  is  to  say,  the  individual  pulse-waves  are  of  like  volume  and  follow 
one  another  at  equal  intervals  of  time.  Physiological  derangements  of 
rhythm  are  slight  and  transient  and  occur  under  those  physiological  con- 
ditions which  are  attended  by  changes  in  the  pulse-frequency.  Marked 
disturbances  of  rhythm — arrhythmia — are  always  pathological  and  have 
their  source  either  in  functional  derangements  of  the  heart  or  demon- 
strable lesions  of  that  organ. 

The  causes  of  the  various  disturbances  of  rhythm  are,  (a)  psychic  or 
emotional,  (b)  organic  cerebral  disease,  as  endarteritis,  hemorrhage,  con- 
cussion, or  compression,  (c)  reflex,  such  as  produce  the  cardiac  irregularity 
in  gastro-intestinal  derangements  and  diseases  of  the  liver,  kidneys,  or 
genito-urinary  organs,  (d)  toxic,  the  common  agents  being  tea,  coffee, 
tobacco,  and  alcohol,  and  finally  (e)  changes  in  the  heart  itself. 

Arrhythmia.     The  following  types  are  to  be  considered: 

1.  Respiratory  arrhythmia:  Sinus  Irregularity  of  Mackenzie;  Pulsus 
Respiratorius. — Variation  in  the  length  of  the  diastolic  period  is  the  chief 
characteristic,  the  systolic  period  remaining  constant.  The  normal  inspir- 
atory increase  and  expiratory  decrease  of  the  cardiac  action  are  exag- 
gerated. It  is  easily  recognized,  pulse  beats  of  equal  strength  but  frequency 
continuously  changing  with  the  phases  of  the  respiration  being  recognized 
by  the  finger  and  upon  auscultation.  With  marked  slowing  of  the  inspira- 
tion, the  pulse  shows  this  irregularity  with  great  constancy.  This  form  of 
arrhythmia  is  of  vagus  origin  and  is  attributed  to  an  exaggeration  of  the 
normal  respiratory  reflex.  Jugular  tracings  show  that  the  right  auricle  and 
ventricle  contract  with  the  same  irregular  rhythm  as  the  radial  pulse.  It  has 
been  observed  in  infants,  healthy  adolescents  and  less  frequently  in  healthy 
adults  and  is  not  uncommon  in  the  convalescence  from  the  acute  febrile 
infections,  in  cerebral  disease,  especially  tuberculous  meningitis,  neurasthenia 
and  anaemic  states.    It  is  of  no  great  diagnostic  significance. 

2.  Extrasystole  ;  Pulsus  Extrasystolicus. — According  to  Mackenzie 
this  term  should  be  limited  to  "  premature  contractions  of  the  auricle  or 
ventricle  in  response  to  a  stimulus  from  some  abnormal  point  of  the  heart, 
but  when  otherwise  the  fundamental  or  sinus  rhythm  of  the  heart  is  main- 
tained." As  the  primary  automatic  stimulus  for  contraction  arises  normally 
in  the  remains  of  the  sinus  venosus  at  the  mouths  of  the  great  veins — sino- 
auricular  node — and  since  this  primitive  cardiac  tube  is  represented  in  the 
auricle — atrio-ventricular  node — and  in  the  bundle  of  His  and  its  extension 
to  the  ventricles,  and  each  section  of  the  heart  is  capable  of  independent 
automatism,  the  following  forms  of  extrasystole  occur: 


SYMPTOMS  AND  SIGNS:   RADIAL  PULSE.  485 

a.  Ventricular  Extrasystole. — The  origin  of  the  extrasystole  is 
assumed  to  be  in  the  atrio-ventricular  bundle  beyond  the  atrio-ventricular 
node.  The  ventricle  contracts  in  advance  of  its  normal  time.  This  con- 
traction is  followed  by  the  usual  refractory  period  during  which  the  ven- 
tricle fails  to  react  to  the  normal  stimulus  from  the  sino-auricular  node  with 
the  occurrence  of  a  compensatory  pause  which  is  longer  than  the  normal 
diastolic  pause  by  so  much  as  to  make  up  the  loss  in  duration  of  the  pre- 
ceding diastole  and  is  followed  by  a  forcible  postcompensatory  systole  in 
response  to  the  succeeding  rhythmic  stimulus  from  the  sino-auricular  node. 
It  is  characteristic  of  the  ventricular  extrasystole  that  the  compensatory 
pause  plus  the  diastole  preceding  the  extrasystole  =  two  normal  diastoles. 

b.  Auricular  Extrasystole. — The  stimulus  arises  in  the  remains  of 
the  primitive  cardiac  tube  incorporated  in  the  auricle  below  the  level  of  the 
sinus.  The  premature  auricular  contraction  is  followed  by  ventricular 
contraction  and  a  long  pause  after  the  extrasystole  due  to  the  fact  that  the 
normal  rhythmic  stimulus  from  the  sinus  occurs  during  the  refractory  period 
of  the  auricle.  The  auricle  and  ventricle  are  quiescent  until  the  occurrence 
of  the  next  sinus  stimulus.  In  auricular  extrasystole  the  pause  is  not 
usually  fully  compensatory.  The  sounds  of  the  heart  and  the  radial  pulse 
do  not  differ  from  those  of  ventricular  extrasystole  from  which  auricular 
extrasystole  can  only  be  differentiated  by  simultaneous  tracings  of  the 
jugular  pulse. 

c.  Auricular  Ventricular  Extrasystoles;  Nodal  Extrasystoles. 
— This  form  of  extrasystole  is  attributed  by  Mackenzie  to  an  abnormal 
stimulus  originating  in  the  auriculo-ventricular  node  of  Tawara  and  causing 
premature  and  simultaneous  contractions  of  auricles  and  ventricles.  Other 
observers  regard  it  as  a  ventricular  extrasystole  in  which  the  stimulus  has 
passed  back  and  prematurelystimulated  the  auricle — "a  retrograde  auricular 
systole." 

Extrasystoles  constitute  the  most  common  causes  of  arrhythmia. 
They  may  occur  at  regular  or  irregular  intervals,  during  more  or  less  pro- 
longed periods  or  continuously,  and  these  three  forms  of  extrasystole  may 
be  present  in  varying  combination  or  in  association  with  other  forms  of 
arrhythmia.  They  are  attributed  to  an  undue  excitability  of  the  remains 
of  the  primitive  cardiac  tick.  Most  patients  experience  no  subjective  symp- 
toms in  connection  with  the  occurrence  of  extrasystoles.  When,  however, 
their  attention  is  called  to  the  irregularity,  they  are  often  unnecessarily 
annoyed  by  various  precordial  sensations  described  as  "fluttering,"  "heart 
dropping"  or  the  "strong  beat"  which  often  follows  the  long  pause.  Extra- 
systoles are  of  common  occurrence  in  neurotic  individuals  under  various 
circumstances,  especially  excitement  or  exertion,  in  advanced  life,  at  pub- 
erty, the  climacteric  and  during  pregnancy;  in  habitual  over-indulgence  in 
tobacco,  tea,  coffee  or  alcohol;  in  the  convalescence  from  the  acute  febrile 
infections  and  in  arterio-  and  cardio-sclerosis.  They  are  essentially  of 
minor  clinical  importance  but  the  conditions  of  winch  they  are  symptomatic 
are  often  grave.  Pulsus  bigeminus  is  that  form  of  irregularity  in  which 
every  second  beat  is  an  extrasystole  and  is  usually  smaller  than  the  normal 
beat.  The  smaller  beat  is  invariably  followed  by  a  pause  longer  than  the 
pause  preceding  it.     The  extrasystole  may  appear  after  every  1,  2,  3,  4  or 


486  MEDICAL   DIAGNOSIS. 

more  normal  beats  and  on  account  of   the  long  compensatory  pause  is 
spoken  of  as  an  intermission  or  the  "dropping  of  a  beat." 

3.  Nodal  Rhythm  —  Continuous  Irregularity  ;  Rhythm  of  Auricular 
Fibrillation — Ventricular  Rhythm  ;  Pulsus  Irregularis  Perpetuus. — Accord- 
ing to  Mackenzie  the  automatic  impulse  starts  at  the  auriculo-ventricular 
node  and  the  auricles  and  ventricles  contract  nearly  at  the  same  time; 
according  to  Cushny  the  arrhythmia  is  due  to  fibrillation  of  the  auricle 
which  ceases  to  contract  as  a  whole.  The  condition  is  characterized  by 
extreme  and  continuous  irregularity  of  the  action  of  the  heart — perpetual 
irregularity;  delirium  cordis — by  the  absence  of  the  sinus  rhythm,  the 
presence  of  a  ventricular  or  positive  venous  pulse  and  the  absence  of  an 
auricular  wave  in  the  jugular  tracing.  The  nodal  rhythm  is  present  in  the 
majority  of  cases  of  severe  heart  failure  and  in  a  great  many  the  immediate 
breakdown  is  directly  attributed  to  the  inception  by  the  heart  of  this 
abnormal  rhythm.  (Mackenzie.)  The  heart's  action  may  be  (a)  not 
greatly  increased  and  the  evidences  of  cardiac  insufficiency  may  not  be 
marked  for  a  long  time,  or  (b)  it  may  be  greatly  increased.  Sensations  of 
fluttering  in  the  left  chest  and  rapidly  developing  symptoms  of  cardiac 
insufficiency  occur.  The  pulse  is  small,  rapid  and  except  when  extremely 
rapid  very  irregular  in  tachycardia;  and  (c)  the  nodal  rhythm  is  transient 
and  recurrent;  see  Paroxysmal  Tachycardia.  The  significance  of  the  nodal 
rhythm  is  grave.  Improvement  in  the  underlying  cardiac  condition  may 
occur  under  rest  and  the  administration  of  digitalis,  but  it  is  transient  and 
exertion  is  almost  always  followed  by  a  recurrence  of  the  symptoms. 

4.  Partial  or  Complete  Heart  Block;  Ventricular  Rhythm;  Pulsus  Trans- 
missionus. — This  form  of  arrhythmia  is  attributed  to  partial  or  com- 
plete impairment  of  the  conductivity  of  the  bundle  of  His.  The  ventricle 
fails  to  contract  after  the  auricular  contraction.  The  stimulus  may  be 
delayed  or  at  times  prevented  from  passing  over,  or  finally  it  may  be  com- 
pletely blocked  beyond  the  auricular  ventricular  node  and  the  contraction 
of  the  ventricle  then  arises  in  response  to  a  stimulus  originating  in  the 
functionating  remains  of  the  bundle  of  His — Heart  Block;  Ventricular 
Rhythm. 

5.  Pulsus  Alternans;  Exhaustion  of  Contractility. — This  form  of 
arrhythmia  is  characterized  by  an  alternating  succession  of  large  and  small 
beats,  the  rate  of  the  heart  remaining  perfectly  regular.  It  indicates  weak- 
ness of  the  heart  muscle.  The  large  contraction  encroaches  upon  the  period 
of  rest  so  that  contractility  has  not  sufficiently  recovered  to  fully  react  to 
the  next  stimulus,  hence  the  smaller  beat  due  to  diminished  energy  of  the 
heart  muscle  at  the  moment.  The  smaller  contraction  is  in  turn  followed 
by  a  longer  period  of  rest  and  a  correspondingly  larger  pulse  beat.  Pulsus 
alternans  is  not  to  be  confounded  with  extrasystole. 

Volume.- — The  volume  is  the  size  of  the  artery  under  the  influence  of 
the  pulse-wave.  It  depends  upon  the  degree  of  relaxation  of  the  muscular 
coat.  If  the  expansion  is  marked  the  volume  is  correspondingly  great  and 
the  pulse  is  said  to  be  large  or  full — pulsus  magnus.  If  the  expansion  is 
slight  the  pulse  is  said  to  be  small — pulsus  parvus.  The  large  pulse  is  com- 
monly a  pulse  of  low  tension.  The  small  pulse  varies  in  tension.  If  low  it 
is  the  sign  of  feeble  action  of  the  heart  or  diminished  amount  of  blood.    The 


SYMPTOMS    AND    SIGNS:    RADIAL    PULSE. 


487 


pulse  is  small  and  of  low  tension  in  valvular  disease  of  the  heart  with 
ruptured  compensation,  and  small  and  usually  of  good  tension  in  aortic  and 
mitral  stenosis. 

Celerity. — There  is  an  important  distinction  between  the  frequency 
of  the  pulse,  that  is,  the  number  of  beats  in  a  minute,  and  the  mode  in  which 
the  pulse-wave  develops  under  the  finger.  The  pulse  is  said  to  be  quick — 
pulsus  celer — when  it  is  characterized  by  a  wave  of  rapid  ascent  and  equally 
rapid  recedence.  The  quick  pulse  is  a  pulse  of  low  tension.  It  is  encountered 
when  the  peripheral  vessels  are  relaxed,  as  in  the  fevers  and  in  various  forms 
of  anaemia.  Celerity  is  characteristic  of  the  water-hammer  pulse  of  aortic 
insufficiency.     This  pulse  occurs  also  in  consequence  of  the  extreme  relaxa- 


Fig.  198. — A,  alternating  pulse  of  a  case  of  paroxysmal  tachycardia;  B,  pulsus  bigeminus.  Tracing 
from  jugular  vein  (V.J.D.)  and  brachial  artery  (A.B.R.)  showing  ventricular  extrasystoles;  C,  pulsus 
trigeminus.  Tracing  from  jugular  vein  and  brachial  artery  showing  two  auricular  extrasystoles  (E,E) 
after  regular  systole. 

tion  of  the  peripheral  arteries  in  many  cases  of  neurasthenia.  In  these  con- 
ditions there  is  often  a  visible  pulsation  in  the  superficial  arteries  associated 
with  capillary  and,  in  some  instances,  with  venous  pulsation. 

The  tardy  pulse — pulsus  tardus — is  characterized  by  the  gradual  rise 
and  equally  gradual  descent  of  the  pulse-wave.  It  is  a  pulse  of  high  tension 
and  is  encountered  in  arteriosclerosis,  advanced  age,  chronic  interstitial  ne- 
phritis, and  in  some  instances  during  the  attacks  of  angina  pectoris.  The  pulse 
in  aortic  stenosis  and  in  arteries  peripheral  to  an  aneurism  is  commonly  tardy. 

Tension. — This  term  includes  those  qualities  of  the  pulse  which  indi- 
cate the  arterial  blood-pressure.  On  the  one  hand  the  adjectives  hard  and 
tense  are  sometimes  used  interchangeably  in  regard  to  the  pulse, — pulsus 
durus, — while  on  the  other  hand  the  adjective  soft  is  used  synonymously 
with  relaxed — pulsus  mollis.  The  clinician  must,  however,  be  constantly 
on  his  guard  against  confounding  rigidity  of  the  arterial  wall  with  intra- 
arterial tension  or  blood-pressure.  It  is  important  also  to  distinguish  between 
the  tension  corresponding  to  the  ventricular  systole  and  that  correspond- 
ing to  the  ventricular  diastole. 

High  tension  occurs  in  chronic  interstitial  nephritis,  gout,  lead  poison- 
ing, and  in  the  diabetes  of  advanced  age.  The  pulse  is  small  and  tense  in 
the  early  Btagee  of  acute  peritonitis.  The  pulse  tension  is  increased  in  preg- 
nancy and  in  some  forms  of  amemia. 


488  MEDICAL   DIAGNOSIS. 

The  pulse  of  low  tension  is  soft  and  compressible.  It  is  a  sign  of  cardiac 
and  general  asthenia  and  occurs  in  all  forms  of  depression  and  exhaustion. 
The  pulse  of  obese  persons  is  very  often  of  low  tension.  Temporary  diminu- 
tion of  arterial  tension  may  follow  hot  drinks,  alcoholic  beverages,  the  hot 
bath,  and  accompany  the  period  of  reaction  following  great  physical  exertion 
or  mental  excitement.  The  statement  is  very  often  made  that  arterial  ten- 
sion increases  with  age.  The  clinician  will  do  well  to  recognize  the  distinction 
between  histological  changes  in  the  arterial  walls  and  increase  of  intra-arterial 
pressure.  When  the  diastolic  pressure  is  relatively  high  and  the  artery  re- 
mains well  filled  between  the  beats,  the  pulse  is  said  to  be  full — pulsus  plenus. 
When  the  pulse-wave  is  very  full  and  quick  and  the  vessels  are  soft  and  com- 
pressible, the  pulse  is  sometimes  spoken  of  as  gaseous.  When  the  artery  is 
collapsed  between  the  beats,  the  pulse  is  said  to  be  empty — pulsus  vacuus,  vel 
inanis.  When  the  pulse-wave  is  very  small  and  the  artery  relaxed,  the  pulse 
is  described  as  thready,  running,  or  undulatory. 

The  blood-pressure — arterial  tension — may  be  estimated  by  the  fingers; 
but  more  exact  and  definite  measurements  are  made  by  various  forms  of 
sphygmomanometers. 

Dicrotism. — The  occurrence  of  a  secondary  pulse-wave  in  each  arterial 
beat  is  commonly  shown  in  normal  sphygmographic  tracings.  It  is  recog- 
nized by  the  finger  only  when  fairly  well  marked.  The  conditions  which 
favor  dicrotism  are:  diminished  arterial  tension,  relaxed  capillaries, — both 
of  which  are  due  to  diminished  vasomotor  tonicity, — a  sudden  forcible  ven- 
tricular systole,  and  relaxation  of  the  arterial  walls.  Dicrotism  may  be  oc- 
casionally recognized  by  the  finger  in  persons  apparently  in  good  health. 
Such  individuals  usually  manifest  a  high  degree  of  vasomotor  instability,  are 
easily  fatigued  and  bear  acute  illness  badly.  The  clinical  condition  in  which 
dicrotism  is  most  marked  is  fever.  It  is  usually  well  developed  in  enteric 
fever  from  the  beginning  of  the  second  week. 

OTHER  ANOMALIES  OF  THE  PULSE. 

The  pulse  should  be  examined  not  only  in  both  radials  but,  under  cer- 
tain circumstances,  in  the  superficial  arteries  elsewhere.  Retardation,  small- 
ness,  feebleness,  or  obliteration  of  the  pulse  on  one  side  of  the  body  or  locally 
may  be  caused  by  deviations  from  normal  anatomical  standards  or  by  trau- 
matism, embolism,  thrombosis,  tumor  pressure,  and  aneurism. 

If  the  pulse  be  relatively  feeble  or  small,  or  if  it  be  absent  in  the  right 
radial,  it  may  indicate  an  aneurism  of  the  ascending  aorta  or  innominate;  in 
the  left  radial,  an  aneurism  of  the  transverse  or  descending  portion  of  the  arch; 
in  a  radial  of  either  side  it  may  indicate  the  presence  on  the  same  side  of  em- 
bolism, thrombosis,  aneurism  of  the  subclavian,  axillary,  or  brachial  arteries, 
cervical  or  axillary  tumors  exerting  pressure  upon  the  vessel,  and  if  slight  in 
degree  may  be  suggestive  of  pneumothorax  or  large  pleural  effusion;  in  one 
femoral,  popliteal,  or  posterior  tibial  artery  the  interference  of  the  circulation 
may  be  due  to  aneurism,  tumor  pressure,  embolism,  or  thrombosis;  in  these 
vessels  on  both  sides,  to  abdominal  aneurism  or  congenital  obliteration  of  the 
aorta.  Absence  of  pulse  in  the  femorals  is  an  occasional  sign  of  aneurism  of 
the  abdominal  aorta. 


SYMPTOMS  AND  SIGNS:    CAPILLARY  PULSE.  489 

The  Pulse  in  Different  Conditions  of  the  Heart — Myocarditis. — In  the 
various  forms  of  sclerosis  the  pulse  is  usually  feeble.  It  is  sometimes,  but  not" 
invariably,  irregular.  It  is  commonly  slow,  and  not  infrequently  bradycardia 
is  present,  the  pulse  falling  as  low  as  30  or  40  per  minute.  In  fatty  heart  the 
pulse  may  show  the  same  characteristic.  Extreme  fatty  changes  occur,  how- 
ever, without  modification  of  the  pulse,  which  may  remain  regular  and  of 
moderate   strength. 

Mitral  Stenosis. — In  the  early  stages  the  frequency  of  the  pulse  is 
not  increased.  It  is  small  and  rather  tardy,  the  artery  not  well  filled,  the  suc- 
cessive beats  irregular  in  time  and  volume. 

Mitral  Incompetence. — The  modifications  depend  upon  the  extent 
of  the  lesion  and  the  condition  of  the  left  ventricle.  The  frequency  is  in- 
creased, the  volume  and  tension  are  diminished,  the  rhythm  usually,  but  by 
no  means  constantly,  irregular. 

Aortic  Stenosis. — In  uncomplicated  cases  the  pulse  is  slow,  its  vol- 
ume diminished,  its  tension  maintained,  the  artery  being  well  filled  during 
the  ventricular  diastole.    The  pulse  of  aortic  stenosis  is  usually  regular. 

Aortic  Incompetence. — The  large  mass  of  blood  propelled  into  the 
aorta  by  the  dilated  and  hypertrophied  left  ventricle  causes  sudden  disten- 
tion of  the  arterial  system,  which  is  followed  by  an  equally  sudden  collapse 
resulting  from  the  failure  of  the  base  of  support  to  the  column  of  blood  nor- 
mally supplied  by  the  aortic  valves;  characteristic  and  striking  changes  in 
the  arterial  pulse  result,  and  are  manifested  in  all  the  superficial  arteries. 
The  pulse  is  increased  in  frequency  and  usually  regular.  The  artery  is  sud- 
denly distended,  the  pulse  being  quick,  jerking,  visible,  and  abruptly  receding. 
The  pulse  is  locomotor,  that  is  to  say,  the  visible  arteries  are  elongated  and 
their  curves  accentuated.  The  jerking,  visible,  and  collapsible  character  of 
the  pulse,  as  observed  in  the  arm  and  wrist,  is  intensified  by  elevating  the 
member  above  the  head.  Very  often  there  is  pulsation  at  the  root  of  the  neck, 
and  in  well-developed  cases  there  is  distinct  pulsation  of  the  tissues  of  the 
hands  and  feet — capillary  pulse — which  may  be  felt  by  gently  grasping  the 
hand  or  foot,  placing  the  thumb  upon  the  palmar  or  plantar  surface  and  the 
fingers  upon  the  dorsal  surface.  With  the  ophthalmoscope  pulsation  of  the 
retinal  arteries  majr  be  seen.  Capillary  and  the  so-called  penetrating  venous 
pulsation  also  occur. 

The  pulse  of  aortic  incompetence  is  frequently  called  the  Corrigan  pulse, 
after  Sir  Dominic  Corrigan,  who  first  sj'stematically  studied  and  described 
its  peculiarities. 

Arteriosclerosis. — Modifications  of  the  pulse  in  arteriosclerosis  de- 
pend upon  the  peripheral  resistance  and  the  force  of  the  ventricular  systole. 
Sclerosis  and  high  tension  are  usually  associated.  The  pulse-wave  is  tardy, 
BUstained,  and  subsides  slowly,  the  vessel  remaining  full  between  the  beats — 
diastolic  tension.  Pressure  of  the  finger  does  not  readily  obliterate  the  pulse. 
An  effort  must  be  made  to  discriminate  between  the  firmness  due  to  intra- 
arterial tension  and  that  due  to  thickening  of  the  arterial  wall.  If,  when  the 
pulse-wave  is  arrested  by  the  pressure  of  the  finger,  the  artery  can  be  felt  be- 
yond the  point  of  compression,  its  walls  are  thickened. 


490  MEDICAL   DIAGNOSIS. 


CAPILLARY  PULSE. 

Normally  the  pulse-waves  penetrate  to  the  smallest  arteries  but  are 
lost  in  the  capillaries.  Under  certain  circumstances,  however,  the  pulse  is 
manifest  in  the  capillaries  and  shows  itself  upon  inspection  as  a  pulsatile 
flushing  and  fading  of  the  surface.  Conditions  which  especially  favor  the  de- 
velopment of  the  capillary  pulse  are  relaxation  of  the  peripheral  circulation 
and  rapid  discharge  of  a  large  amount  of  blood  from  the  ventricle  into  the 
arterial  system — pulsus  celer.  Capillary  pulse  is  occasionally  seen  in  areas 
of  local  hyperemia  and  inflammation,  as  in  whitlow,  and  patients  often  rec- 
ognize this  increased  pulsation  in  the  throbbing  character  of  the  pain.  Of 
greater  interest  is  the  capillary  pulse  of  aortic  incompetence.  It  is  seen  in 
the  pulsatile  changing  in  the  color  intensity  of  the  nail-bed — subungual  pulse 
— a  phenomenon  which  becomes  more  marked  when  the  nail  is  slightly  pressed 
near  its  edge  so  that  the  underlying  tissue  is  momentarily  pale.  The  border 
line  between  the  pink  and  white  advances  and  recedes  with  each  cardiac  revo- 
lution. The  capillary  pulse  can  be  distinguished  in  the  ear,  lips,  cheek,  and 
especially  distinctly  upon  the  forehead  at  a  point  where  it  is  reddened  by  light 
rubbing.  The  capillary  pulse  shows  clearly  through  a  piece  of  glass  pressed 
upon  the  mucous  surface  of  the  everted  lip.  It  is,  however,  not  confined  to 
aortic  regurgitation,  but  occurs  also  in  pyrexia,  chlorosis,  and  other  forms  of 
anaemia,  neurasthenia,  and  exophthalmic  goitre.  The  capillary  pulse  of  aortic 
incompetency  is  more  marked  in  stages  in  which  the  compensation  is  good 
and  disappears  upon  the  failure  of  compensation. 

VENOUS  PULSE. 

The  modifications  of  intrathoracic  pressure  caused  by  respiration  are 
of  importance  in  connection  with  the  venous  circulation.  Inspiration  hastens, 
expiration  retards  the  flow  of  blood  in  the  veins.  These  modifications 
are  not  seen  upon  ordinary  quiet  breathing.  On  the  other  hand,  in  forced 
respiration  and  dyspnoea  there  is  expiratory  venous  distention  and  inspira- 
tory venous  collapse,  best  seen  in  the  veins  of  the  neck,  especially  when  they 
have  been  enlarged  by  previous  congestion  and  are  therefore  more  distinctly 
visible.  Even  more  marked  is  the  influence  of  the  variations  of  intrathoracic 
pressure  by  violent  cough  and  prolonged  muscular  effort.  In  individuals  in 
which  these  paroxysms  of  intravenous  pressure  recur  through  long  periods,  as 
in  those  who  suffer  from  chronic  paroxysmal  cough,  the  veins,  especially  the 
jugular,  become  permanently  enlarged,  so  that  during  the  paroxysms  the 
patient  is  not  only  cyanosed  but  manifests  a  distinct  distention  of  the  vessels 
at  the  root  of  the  neck.  The  jugular  bulb  sometimes  appears  as  a  small, 
sausage-like  swelling  in  the  region  of  the  insertions  of  the  sternocleidomastoid 
muscle. 

More  rarely  distention  of  the  veins  takes  place  during  inspiration; 
retraction  upon  expiration.  This  reversal  of  the  ordinary  conditions  is  the 
result  of  mechanical  interference  by  pressure  or  traction  upon  the  great  veins 
within  the  thorax,  such  as  occurs  in  chronic  mediastinitis,  mediastinal  tumors 
or  a  large  pericardial  or  pleural  effusion, — conditions  in  which  Kussmaul's 
pulsus  paradoxus  is  frequently  observed. 


SYMPTOMS  AND  SIGNS:   VENOUS  PULSE.  491 

The  Forms  of  Venous  Pulse. — Pulsation  in  the  veins  is  due  to  the  move- 
ments of  the  heart  and  has  the  cardiac  rhythm.  A  pulsation  communicated 
by  the  underlying  carotids  is  sometimes  seen  in  the  external  jugular  veins. 
This  is  the  so-called  false  venous  pulse.  The  distinction  between  this  and 
true  venous  pulsation  is  usually  unattended  with  difficulty.  The  more 
extended  superficial  pulsation  due  to  the  greater  width  of  the  vein  and  the 
peculiar,  prolonged,  undulatory  movement  which  is  characteristic  of  the  low 
intravenous  tension  are  of  importance.  Upon  light  palpation  the  pulse  is  feeble 
and  compressible  and  in  strong  contrast  to  that  elicited  upon  palpation  of  the 
underlying  artery.  Upon  compression  of  the  vein  the  peripheral  pulsation 
continues  or  may  be  increased  in  consequence  of  the  distention;  upon  com- 
pression of  the  artery  at  the  root  of  the  neck  the  pulsation  wholly  disappears. 

True  Venous  Pulse. — Three  forms  are  encountered:  the  physiological 
or  negative  venous  pulse,  the  regurgitant  or  positive  venous  pulse,  and  the 
penetrating  or  positive  centripetal  venous  pulse. 

(a)  Negative  Venous  Pulse. — This  form  of  pulsation  in  the  veins  is 
called  normal  or  physiological  because  it  is  constantly  seen  in  the  exposed 
veins  of  animals  and  frequently  in  the  jugulars  of  human  beings  in  health. 
It  is  not  observed  in  all  persons,  simply  because  the  jugular  veins  in  many 
individuals  are  difficult  or  impossible  to  distinguish.  It  is  very  obvious 
upon  inspection  in  those  persons  in  whom  the  veins  are  distended  and  plainly 
visible.  The  physiological  venous  pulse  is  readily  distinguished  from  positive 
or  regurgitant  venous  pulsation  by  compression  of  the  vein  with  the  finger. 
The  pulsation  peripheral  to  the  point  of  compression  ceases,  and  that  central 
to  it  likewise  disappears  or  becomes  much  fainter.  The  diminution  or  com- 
plete disappearance  in  the  latter  case  makes  it  evident  that  the  pulse-waves 
are  not  transmitted  to  the  blood  in  the  veins  by  the  cardiac  systole.  It  is 
thus  apparent  that  the  continuous  blood  stream  from  the  veins  is  rhythmic- 
ally restrained  and  hastened  by  the  action  of  the  heart.  The  negative  venous 
pulse  is  observed  in  the  external  and  internal  jugulars.  It  is  presystolic  in 
time.  The  collapse  of  the  vein  at  the  time  of  the  ventricular  systole  is  at- 
tributed to  the  negative  intrathoracic  pressure  caused  by  the  diminution  in 
the  size  of  the  heart  at  that  moment  in  its  revolution.  During  the«ventricular 
diastole  the  aspiration  influence  ceases  and  the  blood  accumulates  in  the 
veins.  It  may  be  urged  against  this  statement,  however,  that  the  venous 
pulse,  central  to  the  point  of  compression,  though  always  reduced,  does  not 
in  all  cases  wholly  disappear;  but  the  external  jugular  cannot  be  entirely 
emptied  of  blood,  as  there  are  tributary  veins  central  to  the  point  of  com- 
pression. In  some  cases  this  form  of  venous  pulsation  can  be  still  further 
reduced  by  simultaneous  compression  of  the  subclavian.  In  order  to  deter- 
mine the  time  of  the  venous  pulse,  which  is  diastolic, — presystolic, — it  must 
be  compared  with  the  carotid  pulse,  which  is,  of  course,  systolic.  The  neg- 
ative  venous  pulse  is  without  diagnostic  significance.  A  knowledge  of  it  is 
necessary,  however,  in  order  that  it  may  be  differentiated  from  the  form 
about  to  be  described. 

(1))  Positive  or  Regurgitant  Venous  Pulse. — This  form  of  venous 
pulsation  is  observed  in  tricuspid  incompetence.  During  the  ventricular 
systole  thr  Mood  regurgitates  into  the  right  auricle  and  the  pulse-wave  is 
transmitted  to  the  vein.     The  pulsation  is  presystolic-systolk  rather  than 


492  MEDICAL   DIAGNOSIS. 

purely  systolic,  as  in  the  case  of  the  arterial  pulse.  When  the  valve  in  the 
jugular  is  competent  the  pulsation  is  more  marked  in  the  bulb,  but  it  does 
not  always  cease  at  the  level  of  the  valve  even  when  competent.  The  regur- 
gitation is  interrupted,  but  a  positive  pulse-wave  of  similar  form,  though 
weaker,  is  induced  in  the  blood  which  accumulates  above  the  valve.  In  some 
instances  the  closure  of  the  valve  under  the  influence  of  the  regurgitant  blood 
wave  gives  rise  to  a  sound  distinctly  audible  upon  auscultation.  In  the  ma- 
jority of  instances,  as  a  result  of  the  over-distention  of  the  veins,  the  valve 
becomes  insufficient,  so  that  the  positive  pulse  is  equally  perceptible  over  the 
upper  portion  of  the  jugular.  The  distinction  between  the  positive  and 
negative  venous  pulse  rests  upon  the  correspondence  of  the  former  with  the 
carotid  pulse  and  its  persistence  in  the  pulsating  vein  below  the  point  of  com- 
pression.    As  a  rule,  positive  venous  pulsation  is  observed  only  in  the  jugulars. 

This  form  of  pulsation  is  a  sign  of  tricuspid  incompetence.  It  has,  how- 
ever, been  observed  in  two  extremely  rare  conditions  in  which  the  lesions 
likewise  favor  the  transmission  of  the  systolic  pulse-wave  to  the  jugular  veins, 
namely,  mitral  incompetence  with  persistent  foramen  ovale  and  aneurism 
of  the  aorta  communicating  with  the  descending  vena  cava. 

The  patient  should  be  examined  in  the  recumbent  posture  and  during 
very  quiet  breathing.  Before  making  compression  in  the  course  of  the  vein 
the  finger-nail  should  be  placed  upon  the  vein  at  the  root  of  the  neck  and 
lightly  drawn  upward  to  empty  the  vessel.  In  the  absence  of  regurgitation 
the  vein  refills  slowly,  but  if  the  tricuspid  valves  be  incompetent  the  vein 
quickly  refills  from  below  and  again  pulsates. 

Pulsation  of  the  Liver. — In  advanced  cases  of  tricuspid  incompetence 
the  liver  becomes  enlarged  and  the  hepatic  veins  dilated  and  engorged.  In 
this  condition  the  organ  pulsates,  the  regurgitant  wave  being  transmitted 
through  the  inferior  vena  cava.  The  pulsation  may  be  recognized  upon  pal- 
pation, one  hand  being  placed  over  the  cartilages  of  the  lower  ribs  to  the  right 
of  the  ensiform  cartilage,  and  the  other  upon  the  side  at  the  costal  margin. 
An  expansive  pulsation  of  the  entire  organ  can  be  felt  with  each  cardiac  im- 
pulse. In  marked  instances  liver  pulsation  may  be  made  out  upon  inspection. 
Pulsation  of  the  liver  must  be  distinguished  from  the  jogging  of  the  organ  by 
a  powerfully  acting  hypertrophied  heart.  It  must  also  be  distinguished  from 
the  epigastric  pulsation  of-  the  abdominal  aorta — dynamic  pulsation — and 
from  aneurismal  pulsation.  In  very  rare  cases  of  aortic  regurgitation,  with 
good  compensation  and  no  sign  of  tricuspid  incompetence,  an  arterial  liver 
pulse  has  been  noted,  and  local  pulsation  with  double  murmur  has  been 
observed  in  acute  cholangeitis. 

(c)  Penetrating  or  Positive  Centripetal  Venous  Pulse. — This 
rare  phenomenon  is  due  to  the  fact  that  under  certain  conditions  the  pulse- 
wave  is  not  lost  in  the  capillaries  but  transmitted  through  them  to  the  smaller 
veins.  It  has  the  same  significance  as  the  capillary  pulse  and  occurs  in  cases 
of  aortic  incompetence  or  neurasthenia  with  great  vasomotor  relaxation.  It 
has  been  observed  in  cases  in  which  the  capillary  pulse  has  been  faintly  per- 
ceptible or  absent  altogether.  It  is  associated  with  quick  arterial  pulse  of 
large  volume  and  is  manifest  not  in  the  jugulars  but  in  the  small  veins  of 
the  extremities,  and  disappears  upon  compression  in  the  central,  not  in  the 
peripheral,  portion  of  the  compressed  vein. 


SYMPTOMS  AND  SIGNS  :    LIPS.  493 

In  this  connection  diastolic  collapse  of  the  cervical  veins,  the  so-called 
Friedreich's  sign,  may  be  mentioned.  This  sign  occurs  in  chronic  adhesive 
pericarditis  but  is  of  no  great  diagnostic  value.  The  collapse  of  the  veins 
is  due  to  diastolic  intrathoracic  aspiration.  The  mechanism  is  the  reverse 
of  that  in  the  physiological  venous  pulse. 


VII. 
THE  DIGESTIVE  SYSTEM:    MOUTH;    LIPS;   TEETH;    GUMS; 

TONGUE. 

THE   MOUTH. 

The  most  important  method  of  examination  is  inspection.  The 
patient  should  be  placed  in  a  good  light.  The  illumination  is  more  satis- 
factory by  light  reflected  from  a  head  mirror.  The  mouth  should  be  opened 
widely  and,  according  to  the  part  to  be  examined,  the  tongue  should  be 
protruded,  drawn  back,  or  moved  from  side  to  side.  The  soft  palate  and 
pharynx  are  best  seen  upon  depression  of  the  base  of  the  unprotruded 
tongue  with  a  spatula  or  the  handle  of  a  spoon.  These  instruments,  if 
introduced  too  far,  cause  gagging.  The  examination  of  the  posterior  wall 
of  the  pharynx  is  facilitated  when  the  patient  pronounces  the  broad  a, 
thus  elevating  the  soft  palate.  In  conditions  of  delirium  or  unconscious- 
ness and  in  insane  patients  the  examination  of  the  mouth  is  often  attended 
with  great  difficulty.  In  some  instances  holding  the  nose  will  cause  the 
patient  to  open  his  mouth;  in  others,  if  necessary,  the  patient  must  be 
anaesthetized.  In  the  case  of  children  the  examination  is  best  conducted 
when  the  physician  and  mother  or  nurse  sit  viz-a-viz,  the  body  of  the  child 
resting  upon  the  knees  of  the  latter,  who  holds  his  hands,  the  head  upon 
the  lap  of  the  former,  who  opens  the  mouth  and  depresses  the  tongue 
with  the  spatula.  The  pharynx  is  best  seen  at  the  beginning  of  gagging. 
Palpation  by  means  of  the  finger  is  very  useful  in  detecting  the  presence 
and  location  of  foreign  bodies,  the  existence  of  retropharyngeal  abscess, 
and  especially  adenoid  vegetations  in  the  nasopharynx  and  other  similar 
conditions.  This  manoeuvre,  which  is  very  annoying  to  the  patient,  must  be 
executed  rapidly.  In  the  case  of  unruly  patients  or  children  the  danger  of 
being  bitten  is  not  to  be  overlooked.  Against  this  accident  a  guard  or 
shield  may  be  employed,  or  the  physician  may,  with  the  thumb  and  finger 
of  the  free  hand,  press  the  cheeks  of  the  patient  between  the  separated 
molars. 

THE   LIPS. 

• 

The  lips  are  thick  and  coarse  in  habitual  mouth-breathers,  in  cretin 
ism,  and  in  myxoedema.    They  are  parted  in  conditions  of  greal    prostra- 
tion and  habitually  in  idiots  and  in  some  forms  of  insanity.     They  arc  pallid 
in  anemia  and,  like  the  nail-beds,  early  show  cyanosis  and  the  variations 
in  its  intensity.    The  lips  are  apt  to  be  dry  in  dyspnoea  and  in  obstruction 


494  MEDICAL  DIAGNOSIS. 

to  the  nasal  breathing.  Dryness  of  the  lips  is  associated  with  a  diminu- 
tion or  perversion  of  the  oral  secretion,  as  in  stomatitis,  glossitis,  and  tonsil- 
litis. The  lips  and  mouth  are  dry  and  the  latter  open  in  the  soporose  con- 
dition preceding  dissolution.  There  is  drooling  in  dentition,  mercurial 
salivation,  diphtheritic  paralysis,  bulbar  palsy,  and  idiocy.  In  these  condi- 
tions the  lips  are  apt  to  be  loose  and  pendulous.  Tremor  or  twitching  of 
the  lips  occurs  under  intense  emotion  or  may  be  a  symptom  of  nervous- 
disease.  Convulsive  retraction  of  the  upper  lip  occasionally  occurs  as  a 
sign  of  intense  abdominal  pain.  Of  great  diagnostic  importance  is  the 
occasional  presence  upon  the  lips  of  aphthous  ulceration,  mucous  patches, 
sordes,  rhagades — linear  clefts  or  ulcerations  at  the  corners  of  the  mouth — 
or  the  scars  resulting  from  them.  The  last,  occurring  in  young  children, 
are  suggestive  of  hereditary  syphilis.  Herpes  labialis  is  common  in  certain 
individuals  in,  feverish  colds,  and  occurs  with  such  frequency  in  pneumonia, 
ague,  and  cerebrospinal  fever  as  to  have  diagnostic  value.  It  is  very 
rare  in  enteric  fever.  This  vesicular  eruption  develops  rapidly  upon  an 
inflammatory  base  as  a  single  lesion  or  in  groups,  most  commonly  upon 
the  outer  border  of  the  lip,  occasionally  on  other  parts  of  the  face,  as  the 
nose,  the  cheeks,  or  the  ear.  These  positions  are  indicated  by  qualifying 
adjectives,  as  herpes  labialis,  facialis,  nasalis,  and  the  like.  The  contents 
of  the  vesicles  are  at  first  lymphoid,  later  purulent  and  scanty.  Their 
efflorescence  is  attended  by  annoying  burning  or  itching.  They  rapidly 
undergo  desiccation  with  the  formation  of  thick,  tightly  adherent  scabs. 
The  whole  process  is  of  short  duration. 

In  paralysis  of  the  seventh  nerve  the  angle  of  the  mouth  on  the  affected 
side  is  lowered.  In  drinking,  the  liquid  is  apt  to  escape.  In  smiles  or 
laughter  the  corner  of  the  mouth  is  immobile  and  in  attempts  to  show 
the  upper  teeth  it  is  not  raised.  The  mouth  and  lips  are  drawn  toward 
the  sound  side.  The  labial  sounds  may  not  be  fully  formed.  It  is  im- 
portant to  note  that  the  displacement  of  the  angle  of  the  mouth  may 
be  due  to  loss  of  the  teeth  upon  the  opposite  side  or  to  retraction  as  the 
result  of  scar  formation. 

The  lips  are  extremely  sensitive  and  abscesses  and  acute  inflammatory 
processes  are  attended  with  great  pain.  They  are  sometimes  the  seat  of 
carbuncles.  They  undergo  extensive  necrosis  in  cancrum  oris.  The 
lip  may  be  lacerated  in  the  epileptic  convulsion,  but  this  is  not  common. 
It  may  be  the  seat  of  angioneurotic  oedema  or  may  be  greatly  swollen 
in  consequence  of  the  bites  of  insects.  The  lip  is  occasionally  the  seat 
of  the  initial  lesion  of  syphilis.  It  shows  more  or  less  extensive  super- 
ficial necrosis  extending  out  upon  the  chin  or  cheeks  after  the  taking  of 
corrosive  poisons  and  especially  in  carbolic  acid  poisoning.  Epithelioma 
of  the  lip  is  common.  It  shows  itself  as  an  irregularly  circular  or  oval 
ulcer  with  a  swollen,  infiltrated  base,  usually  upon  the  lower  lip,  de- 
veloping from  a  fissure  or  wart.  At  the  beginning  there  are  alternations 
of  scab  formation  and  open  ulceration.  After  a  time  the  submaxillary 
lymphatics  become  involved. 

The  differential  diagnosis  between  chancre  and  epithelioma  of  the 
lip  is  usually  unattended  with  difficulty.  The  chancre  occurs,  as  a  rule, 
early  in  life,  epithelioma  late.     In  chancre  the  lymphatics  are  involved 


SYMPTOMS  AND  SIGNS  :    TEETH.  495 

early;  in  epithelioma  late.  Chancre  is  commonly  circumscribed  and 
densely  indurated;  epithelioma  tends  to  spread  and  the  induration  is  less 
dense.  Healing  of  the  chancre  is  progressive,  especially  under  treatment; 
in  epithelioma  there  is  a  tendency  to  extend,  with  alternations  of  scab 
formation  and  ulceration.  In  the  former,  constitutional  symptoms  and 
secondary  rashes  occur. 

THE   TEETH. 

The  teeth  are  of  diagnostic  interest.  The  time  of  their  eruption  and 
shedding  in  children  and  their  state  of  preservation  in  adults  are  to  be 
considered.  Dentition  and  teething  are  terms  used  to  describe  the  cutting 
of  the  teeth. 

The  First  Dentition. — The  temporary  or  deciduous  teeth — the  so- 
called  milk  teeth — :are  twenty  in  number;  in  each  jaw  two  central  incisors, 
two  lateral  incisors,  two  canines,  two  first  molars  and  two  second  molars. 
They  appear  with  considerable  regularity  as  to  order  and  time.  Their 
eruption  usually  takes  place  in  groups  of  four. 

The  first  group — the  lower  and  upper  central  incisors,  6  to  9  months. 
An  interval  of  1  to  3  months. 

The  second  group — the  upper  and  lower  lateral  incisors,  8  to  12  months. 
An  interval  of  1  to  3  months. 

The  third  group — the  four  anterior  molars,  12  to  15  months.  An 
interval  to  the  18th  month. 

The  fourth  group — the  four  canines,  18  to  24  months.  An  interval 
of  2  to  3  months. 

The  fifth  group — the  four  posterior  molars,  24  to  30  months. 

Healthy  children  usually  have  from  four  to  eight  teeth  before  they  are 
a  year  old,  and  cut  their  first  molars  between  a  year  and  a  year  and  a  half, 
the  canines  before  the  end  of  the  second  year,  and  should  complete  denti- 
tion by  the  cutting  of  the  second  molars  before  the  middle  of  the  third 
year.  The  first  teeth  are  usually  the  lower  central  incisors.  The  upper 
lateral  incisors  as  a  rule  appear  before  the  lower;  the  upper  first  molars 
usually  precede  the  lower  and  not  infrequently  appear  at  about  the  same 
time  with  the  lower  lateral  incisors. 

Precocious  dentition  occasionally  occurs.  It  is  of  no  special  signifi- 
cance. Delayed  dentition  occurs  as  the  result  of  malnutrition  either  from 
improper  feeding  or  disease.     It  is  especially  common  in  rickets. 

The  eruption  of  the  teeth  in  healthy,  well-nourished  children  com- 
monly takes  place  without  constitutional  disturbance.  At  most  transitory 
loss  of  appetite,  fretfulness,  disturbed  sleep,  a  slight  rise  of  temperature, 
100-102°  F.  (37.7-38.8°  C),  and  derangement  of  the  bowels  are  observed. 
In  feeble  and  poorly  nourished  infants,  especially  in  neurotic  families,  the 
perturbations  caused  by  dentition  may  be  more  severe,  the  foregoing 
symptoms  being  aggravated  and  the  temperature  reaching  higher  levels, 
103-104°  F.  (39.  1  10°  C).  The  accidental  coincidence  of  gastro-intestinal 
derangements,  tonsillitis,  laryngitis,  and  bronchial  catarrh  is  very  com- 
mon, and  the  physician  must  be  on  his  guard  not  to  ascribe  to  dentition 
symptoms  which  are  due  to  other  causes.  On  the  other  hand  there  is 
danger  that  reflex  symptoms  due  to  the  irritation  of  dentition  will  be 


496  MEDICAL  DIAGNOSIS. 

erroneously  interpreted.  For  example,  annoying  spasmodic  cough,  with- 
out fever,  other  constitutional  disturbance  or  rales,  and  manifestly  reflex, 
frequently  accompanies  the  eruption  of  each  group  of  teeth.  Dentition 
may  be  the  exciting  cause  of  general  convulsions  in  feeble,  badly-nour- 
ished, rhachitic,  or  neurotic  children.  The  process  rarely  causes  eclampsia 
in  well-nourished  healthy  babies.  Tension,  tumefaction,  tenderness  of  the 
gums,  and  the  bluish-red  hue  of  deep  congestion  are  indications  for  the 
use  of  the  lancet. 

The  Second  Dentition. — The  permanent  teeth  in  each  jaw  consist  of 
two  central  and  two  lateral  incisors,  two  canines,  four  bicuspids,  and  six 
molars.    Their  eruption  takes  place  in  the  following  order: 

Anterior  molars, sixth  to  seventh  year. 

Central  incisors, seventh  to  eighth  year. 

Lateral  incisors, eighth  to  ninth  year. 

Anterior  bicuspids, tenth  to  eleventh  year. 

Posterior  bicuspids, tenth  to  eleventh  year. 

Canines, eleventh  to  twelfth  year. 

Second  molars, twelfth  to  fourteenth  year. 

Third  molars — wisdom  teeth, eighteenth  to  twenty-fifth  year. 

The  milk  teeth  are  gradually  displaced  by  the  permanent  teeth  and 
three  additional  molars  appear  on  the  sides  of  each  jaw,  so  that  the  twenty 
milk  teeth  are  replaced  by  the  full  set  of  thirty-two  permanent  teeth.  The 
second  dentition  begins  with  the  eruption  of  the  anterior  molars  some- 
where between  the  fifth  and  seventh  years.  Following  these  the  milk 
teeth  are  gradually  shed  in  the  order  in  which  they  appeared,  each  tooth 
being  forthwith  or  shortly  replaced  by  a  permanent  tooth. 

Shape  and  Structure  of  the  Teeth. — Defects  in  the  teeth  are  numer- 
ous, the  most  important  being  abnormalities  of  form,  and  especially  the  de- 
ficient development  of  enamel.  In  badly-nourished,  feeble  children  the 
milk  teeth  are  prone  to  caries. 

The  developing  teeth  are  influenced  by  malnutrition,  stomatitis, 
especially  that  produced  by  mercury,  and  constitutional  diseases,  as 
syphilis  and  rickets.  The  developmental  defects  show  themselves  in  the 
permanent  teeth.  In  rickets  the  teeth  may  be  small  and  badly  formed. 
As  the  result  of  infantile  stomatitis  the  surfaces  of  the  teeth  are  pitted, 
owing  to  deficient  formation  of  enamel;  the  condition  is  sometimes  im- 
properly spoken  of  as  erosion.  These  changes  affect  the  incisors  and  ca- 
nines, which  are  pitted  by  areas  of  default  of  enamel,  and  are  of  a  bad 
color,  showing  a  transverse  furrow  across  all  the  teeth  at  the  same  level; 
the  first  permanent  molars  are  also  involved.  These  furrows  are  attrib- 
uted, probably  correctly,  to  severe  illness  in  early  life  and  are  regarded  as 
analogous  to  furrows  on  the  nails  which  occur  after  serious  disease. 

Hutchinson  Teeth. — In  congenital  syphilis  the  teeth  are  deformed 
and  present  appearances  regarded  by  Hutchinson  as  specific  and  peculiar. 
The  upper  central  incisors  are  affected.  They  are  peg-shaped,  short,  and 
narrow,  being  smaller  at  the  cutting  edge  than  at  the  base.  The  enamel  is 
commonly  well  formed  and  regularly  developed,  but  the  color  is  more 
yellow  than  that  of  the  other  teeth.  At  the  edge  of  the  teeth  there  is  a 
single  concave  notch  of  varying  depth  in  which  the  dentin  is  exposed. 
They  are  called  €Iutchinson,  notched,  or  screw-driver  teeth.    These  defects 


SYMPTOMS  AND  SIGNS  :  GUMS.  497 

are  not  constant  nor  are  they  pathognomonic  of  syphilis,  as  they  are  some- 
times found  in  other  conditions,  especially  rickets.  In  the  presence  of  other 
signs  of  syphilis — rhagades,  keratitis,  iritis,  and  nodes — notched  teeth  ac- 
quire positive  diagnostic  importance. 

Caries. — Carious  and  neglected 
teeth  play  a  very  important  part 
in  the  causation  of  derangements  of 
digestion  from  imperfect  mastica- 
tion, and  are  themselves  not  rarely 
the  result  of  constitutional  disturb- 
ances. Extensive  and  rapid  dental 
caries  may  occur  after  serious  acute 

disease    and    in    constitutional    dis-  Fig.  i99.-Hutchinson'9  tee'th. 

orders  as  rickets  and  diabetes.     It 

also  occurs  in  pregnancy.  The  teeth  become  loose  in  forms  of  stomatitis 
associated  with  swollen  and  ulcerated  gums,  such  as  are  encountered  in 
mercurial  ptyalism,  scurvy,  purpura,  and  phosphorus  poisoning.  Receding 
gums  with  exposure  of  the  neck  of  the  teeth  and  their  ultimate  loss 
occur  from  neglected  salivary  deposits,  pyorrhoea  alveolaris,  and  gouty 
conditions. 

Sordes — literally  filth — is  a  term  applied  to  collections  of  dark  brown 
foul  matter  upon  the  teeth  and  lips  in  low  fevers.  It  consists  of  food, 
epithelial  material,  and  altered  blood,  and  contains  micro-organisms  in 
great  numbers. 

THE  GUMS. 

The  gingival  mucous  membrane  is  pale  in  all  forms  of  anaemia;  it  is 
red  and  spongy  when  the  teeth  are  carious  or  ill-kept.  A  narrow  red  line 
along  J;!ic  margin  is  seen  in  some  cases  of  tuberculosis,  diabetes,  and  in 
cachectic  states;  also  in  alveolar  disease.  The  gums  are  red,  spongy,  and 
ulcerated  as  a  result  of  accumulated  tartar  and  gangrenous  and  mercurial 
stomatitis.     They  are  swollen,  spongy,  and  bleeding  in  scurvy. 

In  lead  poisoning  a  narrow  bluish-black  line  is  seen,  although  not 
invariably,  at  the  margin  of  the  gums.  The  color  is  not  uniform,  but, 
being  due  to  lead  sulphide  deposited  in  the  papillae  of  the  gums,  is  seen 
with  the  magnifying  glass  to  be  stippled.  This  line  may  form  rapidly 
after  exposure  and  disappear  in  the  course  of  a  few  weeks  under  treatment. 
or  it  may  persist  for  months.  It  is  usually  limited  in  extent.  A  similar 
line,  due  to  the  deposition  of  carbon  particles,  has  been  observed  in  miners. 
Such  lines  are  to  be  distinguished  from  the  deposits  of  black  matter  upon 
the  teeth  at  the  line  of  their  juncture  with  the  gums  in  untidy  persons  and 
smokers  who  neglect  the  mouth.  The  latter  disappears  upon  the  use  of  the 
tooth-brush,  or  the  two  lines  may  be  differentiated  by  slipping  the  corner 
of  a  piece  of  writing-paper  under  the  gum.  If  the  pigment  material  is  in 
the  gum  it  stands  out  plainly  against  the  white  paper;  thai  on  the  tooth 
is  not  seen.  It  is  under  certain  circumstances  also  to  be  distinguished 
from  cyanosis  due  to  general  disturbances  of  the  circulation  or  local  in- 
flammatory processes.  In  cyanosis  the  discoloration  is  uniform  and  more 
intense  at  the  edges  of  the  gums  and  disappears  under  pressure. 

32 


498  MEDICAL  DIAGNOSIS. 

THE  TONGUE. 

Great  differences  of  opinion  exist  in  regard  to  the  value  in  diagnosis 
of  signs  presented  by  the  tongue.  To  the  careful  observer  an  exami- 
nation of  the  tongue  yields  information  of  diagnostic  importance.  This 
organ  should  be  studied  with  reference  to  its  motility,  size,  condition  of 
the  mucous  membrane  as  regards  color,  papillae,  dryness,  moisture,  coat- 
ing, and  the  presence  or  absence  of  various  lesions. 

(a)  Motility. — The  manner  in  which  the  tongue  is  protruded  upon 
request  is  often  suggestive.  Under  ordinary  circumstances  the  movement 
is  commonplace  and  familiar.  In  very  ill  patients  the  tongue  is  protruded 
slowly  and  incompletely.  In  the  advanced  stages  of  enteric  fever  the 
patient  protrudes  his  tongue  hesitatingly  and  does  not  immediately  with- 
draw it  unless  requested.  In  chorea  the  tongue  is  thrust  out  with  a  pecu- 
liar jerk  and  immediately  withdrawn.  In  well-marked  cases  it  is  impos- 
sible for  the  patient  to  keep  it  out  for  any  length  of  time.  Spasm  of  the 
muscles  of  mastication  renders  it  impossible  to  protrude  the  tongue.  The 
spasm  may  be  tonic  or  clonic;  in  rare  instances  it  occurs  as  an  independent 
affection.  It  is  usually  part  of  general  convulsive  disease.  In  the  tonic 
form  the  jaws  are  held  forcibly  together — lockjaw.  The  masseter  and 
temporal  muscles  are  tense  and  hard  and  the  spasm  is  frequently  attended 
with  pain.  It  is  an  early  and  prominent  symptom  in  tetanus  and  occurs 
also  in  tetany.  There  is  tonic  spasm  of  the  jaw  muscles  in  trismus  neona- 
torum and  strychnia  poisoning  and  sometimes  in  hysteria  and  epilepsy. 
Trismus  may  follow  exposure  to  cold  or  occur  as  the  result  of  reflex  irri- 
tation in  diseases  of  the  mouth,  teeth  or  jaw  or  of  irritative  lesion  in  the 
region  of  the  motor  nucleus  of  the  fifth  nerve.  Clonic  spasm  of  the  muscles 
of  the  jaw  is  seen  in  the  chattering  of  the  teeth  which  occurs  after  exposure 
to  cold,  in  some  conditions  of  mental  excitement,  and  during  a  chill.  Its 
rare  occurrence  as  a  substantive  affection  has  been  noted.  Pain  and 
swelling  of  the  tissues  about  the  angle  of  the  jaw,  such  as  attend  disease  of 
the  bones,  mumps,  suppurative  tonsillitis,  and  trichinosis  involving  the 
masticatory  muscles,  may  prevent  the  opening  of  the  mouth  and  pro- 
trusion of  the  tongue. 

General  tremor  of  the,  tongue  occurs  in  alcoholism  and  in  conditions 
of  asthenia.  Tremor  and  fibrillary  contractions  are  observed  in  patients 
presenting  bulbar  symptoms  with  atrophy  of  the  tongue  and  may  be  espe- 
cially pronounced  in  progressive  bulbar  atrophy.  Fibrillary  contrac- 
tions are  occasionally  seen  in  healthy  individuals. 

Paralysis  of  the  tongue  results  from  disease  of  the  hypoglossal  nerves. 
When  one  nerve  is  involved  the  base  of  the  tongue  is  slightly  higher  upon 
the  paralyzed  side,  and  motion  within  the  mouth  toward  that  side  is 
impaired.  When  the  tongue  is  protruded  it  deviates  to  the  paralyzed  side, 
being  pushed  by  the  geniohyoglossus  on  the  normal  side;  there  is  slight 
difficulty  in  chewing  and  swallowing.  When  both  hypoglossal  nerves  are 
involved  the  tongue  cannot  be  moved  within  the  mouth  and  cannot  be 
protruded;  mastication  and  articulation  are  greatly  impaired.  Palsy  of 
the  tongue  from  nuclear  disease  is  usually  associated  with  a  similar  condi- 
tion of  the  lips,  pharynx,  and  larynx.     The  power  of  protruding  the  tongue 


SYMPTOMS  AND  SIGNS  :   TONGUE.  499 

is  impaired  in  paresis,  diphtheritic  palsy,  progressive  muscular  atrophy, 
and  some  forms  of  hemiplegia.  Slight  deviation  toward  the  paralyzed 
side  may  occur  in  cases  of  hemiplegia  in  which  the  face  is  affected. 
When  the  fibres  of  the  hypoglossal  are  involved  within  the  medulla  after 
leaving  their  nuclei,  there  may  be  paralysis  of  the  tongue  on  one  side 
and  paralysis  of  the  limbs  on  the  other,  and  the  tongue  when  protruded 
deviates  toward  its  sound  side.  Other  causes  of  nuclear  or  infranuclear 
lesions  of  the  hypoglossal  are  lead  poisoning,  basal  meningitis,  and  tumors 
of  the  base. 

Spasm  of  the  tongue  is  very  rare.  It  may  be  unilateral  or  bilateral 
— tonic  or  clonic.  It  is  usually  one  of  the  manifestations  of  some  other 
convulsive  disease,  as  spasm  of  the  facial  muscles,  tetanus,  epilepsy,  or 
chorea.  Tonic  spasm  may  occur  in  hysteria  and  as  the  result  of  reflex 
irritation  of  the  fifth  nerve.  The  tongue  is  contracted  and  rigid.  Clonic 
spasm  is  much  more  common.  Spasm  of  the  lingual  muscles  occurs  in 
stuttering.  It  is  an  occasional  symptom  in  disseminated  sclerosis,  general 
paresis,  and  melancholia.  There  are  cases  of  paroxysmal  clonic  spasm  in 
which  the  tongue  is  thrust  out  and  drawn  in  as  often  as  forty  or  fifty  times 
a  minute.  In  this  affection  the  spasm  is  usually  bilateral;  the  attacks 
may  occur  during  sleep. 

The  frsenum  of  the  tongue  may  be  abnormally  short — a  congenital 
defect  which,  by  limiting  the  movements  of  the  tongue,  interferes  with 
nursing  in  the  new-born  and  with  articulation  later. 

(b)  Size  of  the  Tongue. — Variations  in  the  size  of  the  tongue  are  of 
diagnostic  importance.  The  tongue  is  slightly  enlarged  and  flabby  in 
various  conditions  of  ill  health  and  especially  in  chronic  gastritis,  forms  of 
anaemia,  scurvy,  and  typhus  fever.  Under  these  circumstances  the  edges 
are  indented  by  the  teeth. 

Enlargement  of  the  tongue,  or  macroglossia,  is  usually  congenital  but 
may  occur  in  later  life.  In  the  congenital  form  the  tongue  and  very  often 
the  lips  are  greatly  enlarged  by  an  increase  in  all  the  tissue  elements,  an 
increase  in  the  fibrous  tissue  alone,  or  from  the  development  of  tumor-like 
masses — true  lymphangioma.  The  organ  may  become  so  large  that  it 
projects  beyond  the  teeth,  in  some  cases  attaining  twice  its  normal  size. 
The  surface  is  dry,  fissured,  or  ulcerated  from  contact  with  the  teeth,  and 
deformity  of  the  bony  structures  results  from  pressure.  The  lymph-vessels 
are  dilated  and  in  some  instances  there  are  actual  cysts. 

Great  enlargement  takes  place  in  acute  inflammation  of  the  tongue, 
such  as  glossitis,  inflamed  ranula,  erysipelas,  angina  Ludovici.  The  tongue 
is  frequently  much  enlarged  in  actinomycosis.  One  side  only  may  be 
involved  in  the  inflammatory  process — hemiglossitis.  The  tongue  is  some- 
what enlarged  in  acromegaly  and  myxcedema.  Localized  swelling  may  be 
caused  by  tumors,  as  gumma  or  carcinoma.  The  tongue  in  rare  instances 
becomes  cyanosed  and  oedematous  from  obstruction  to  the  return  of  the 
venous  blood. 

Diminution  In  the  size  of  the  tongue  may  be  the  result  of  a  temporary 
shrinking  or  of  atrophy.  The  tongue  may  be  uniformly  diminished  in 
size  after  hemorrhage,  during  convalescence  from  enteric  fever,  or  in  con- 
ditions of  advanced  emaciation. 


500  MEDICAL  DIAGNOSIS. 

Atrophy  of  the  tongue  is  the  result  of  disease  in  the  path  of  the  hypo- 
glossal nerve.  If  the  lesion  be  supranuclear  there  is  no  wasting  of  the 
tongue.  There  may  be  some  degree  of  paralysis.  Ordinarily  this  condi- 
tion constitutes  an  element  of  hemiplegia.  In  nuclear  or  infranuclear 
paralysis  the  tongue  is  atrophied  on  one  or  both  sides  according  as  the 
lesion  is  unilateral  or  bilateral.  The  muscular  tissue  is  alone  affected, 
ordinary  sensation  and  taste  remaining  practically  normal.  The  reaction 
of  .degeneration  is  present  in  the  wasted  half  of  the  tongue. 

Facial  hemiatrophy  is  usually  associated  with  hemiatrophy  of  the 
tongue  on  the  same  side.  Local  diminution  in  the  size  of  the  tongue  may 
follow  the  resorption  of  a  gumma  or  extensive  scar  formation  following  a 
deep  ulcer. 

(c)  Mucous  Membrane. — The  color  of  the  organ  itself  is  to  be  dis- 
tinguished from  the  coating.  The  tongue  is  pale  in  anaemia;  red  in  in- 
flammation, as  glossitis  and  stomatitis,  and  in  the  infectious  diseases,  as 
measles,  scarlatina,  and  enteric  fever;  dark  red  in  conditions  of  prostra- 
tion; bluish  in  cyanosis;  yellow  in  jaundice.  It  is  stained  various  colors 
by  ingested  articles — red  or  purple  by  fruits  or  wine,  black  by  iron,  bis- 
muth, or  charcoal,  yellow  by  rhubarb,  tobacco,  or  licorice  root,  brown  by 
chocolate  and  opium.  Ingestion  of  corrosive  substances  may  give  rise  to 
staining  with  superficial  necrosis.  Ammonia,  corrosive  sublimate,  sul- 
phuric, carbolic,  and  oxalic  acids  turn  the  tongue  white;  hydrochloric, 
nitric,  chromic,  and  picric  acids  yellow;  the  caustic  alkalies  turn  it  red. 
Local  discoloration  of  the  tongue  is  caused  by  telangiectatic  patches, 
purpura,  ecchymoses,  and  infarcts.  Patches  of  pigmentation  may  mark 
the  site  of  healed  glossitis  or  occur  as  manifestations  of  Addison's  disease. 
In  the  latter  condition  the  color  is  bluish-  or  grayish-black  and  the  areas  of 
pigmentation  are  associated  with  similar  areas  of  pigmentation  upon  the 
buccal  mucous  membrane  and  the  lips.  The  "black  tongue"  or  nigrities 
is  a  rare  affection  of  parasitic  origin.  It  is  characterized  by  irregular 
areas  of  blackish-brown  or  black  color,  with  enlargement  of  the  papilla?, 
which  occupy  the  middle  of  the  dorsum  of  the  tongue.  The  discoloration 
begins  as  a  small  spot  and  extends;  after  a  time  desquamation  occurs 
which  goes  on  slowly.  The  condition  may  become  chronic.  It  is  to  be 
distinguished  from  staining  of  the  tongue  caused  by  iron,  bismuth,  and 
the  like,  and  from  purposeful  discoloration  in  malingering. 

Moisture. — The  normal  tongue  owes  its  moisture  to  the  buccal  secre- 
tions and  saliva.  A  physiological  increase  of  these  secretions  occurs  in 
hunger  and  is  excited  by  the  sight  or  odor  of  food.  Such  an  increase  is 
also  promoted  by  sapid  and  stimulating  substances  and  by  mastication. 
It  is  called  salivation  or  ptyalism.  It  occurs  during  dentition,  menstrua- 
tion in  some  instances,  often  during  pregnancy — usually  in  the  early 
months  but  sometimes  throughout  the  whole  period.  Jaborandi  and  its 
alkaloid  pilocarpine,  muscarine,  tobacco,  mercury,  gold,  copper,  and  the 
iodine  compounds  excite  an  increased  flow  of  saliva.  A  pathological  in- 
crease of  saliva  occurs  in  forms  of  glossitis  and  stomatitis,  especially  that 
induced  by  mercury,  sometimes  in  the  fevers,  in  the  epileptic  paroxysm, 
and  in  some  forms  of  idiocy  and  nervous  disease.  It  has  been  observed 
in  disease  of  the  pancreas. 


SYMPTOMS  AND  SIGNS  :   TONGUE.  501 

Xerostomia — dry  mouth — is  a  condition  characterized  by  arrest  of 
the  salivary  and  buccal  secretions.  The  condition  is  rare.  It  was  first 
described  by  Jonathan  Hutchinson.  The  tongue  is  red,  dry,  and  fissured; 
the  buccal  mucous  membrane  is  smooth  and  dry.  Movements  of  the  parts 
involved  in  articulation,  mastication,  and  deglutition  are  attended  with 
difficulty.  In  some  cases  the  dryness  extends  to  the  nostrils  and  eyes  and 
is  accompanied  by  distressing  itching.  Slight  enlargement  of  the  salivary 
glands  has  been  observed  but  is  not  constant;  most  of  the  cases  occur  in 
women  of  neurotic  constitution.  In  a  case  under  my  observation  in  a 
woman  aged  thirty  this  condition  developed  during  the  convalescence 
from  an  attack  of  epidemic  influenza.  It  has  been  suggested  that  the 
disease  is  due  to  involvement  of  a  hypothetical  centre  controlling  the 
salivary  and  buccal  secretions. 

Dryness  of  the  tongue  occurs  in  mouth-breathing,  with  thirst,  after 
violent  exertion,  in  febrile  and  septic  states,  conditions  of  profound  pros- 
tration, and  as  the  result  of  loss  of  fluid  in  diabetes  mellitus  and  insipidus. 
It  is  an  important  symptom  of  atropine  poisoning,  and  attends  facial 
paralysis.  Dryness  of  the  tongue  occurs  under  other  conditions  attended 
with  extreme  loss  of  fluid  from  the  body,  as  in  hemorrhage  and  cholera. 

The  papillae  of  the  tongue  are  often  swollen,  giving  it  a  warty,  granu- 
lar appearance.  This  condition  is  seen  in  catarrhal  and  other  forms  of 
stomatitis,  in  some  forms  of  chronic  gastritis,  and  sometimes  in  the  acute 
febrile  infections.  The  enlarged  fungiform  papillae  of  the  tongue  in  scarlet 
fever  have  given  rise  to  the  unfortunate  term  "strawberry  tongue,"  which 
by  some  teachers  is  understood  to  mean  a  tongue  covered  with  a  white 
fur  through  which  the  tip  of  the  papillae  show,  and  by  others  to  mean  the 
rough  bright  red  tongue  which  follows  the  separation  of  the  coating.  The 
latter  is  sometimes  called  the  "raspberry  tongue."  In  conditions  of  pros- 
tration, such  as  attend  the  later,  stages  of  infections  or  sepsis,  and  in  some 
constitutional  diseases,  as  diabetes,  the  tongue  sheds  its  epithelium  and 
the  papillae  undergo  atrophy.  This  condition  is  usually  attended  with 
dryness  and  glossing  of  the  surface.  The  papillae  at  the  border  of  the 
tongue  are  sometimes  greatly  enlarged  in  gouty  individuals.  Patients  are 
occasionally  alarmed  upon  the  discovery  of  the  large  circumvallate  papillae 
at  the  root  of  the  tongue  and  hesitatingly  accept  the  assurance  that  the)' 
are  normal. 

Coating  of  the  Tongue. — This  subject  involves  a  consideration  also 
of  the  general  condition  of  the  mucous  membrane  as  regards  color,  dry- 
ness and  moisture,  and  the  condition  of  the  papillae.  The  presence  or 
absence  of  coating  is  determined  by  local  and  constitutional  conditions. 
It  does  not  follow,  as  is  very  often  assumed,  that  the  condition  of  the 
tongue  is  directly  dependent  upon  the  condition  of  the  mucous  membrane 
of  the  stomach.  On  the  contrary  the  diagnostic  significance  of  coated 
tongue  will  be  best  understood  by  the  clinician  who  realizes  the  fact,  of 
which  there  is  abundant  clinical  demonstration,  that  the  condition  of  the 
tongue  as  regards  coating  and  allied  phenomena  is  largely  dependent  upon 
constitutional  influences  which  are  likewise  exerted  upon  other  mucous 
surfaces.  Coating  of  the  tongue  occurs  in  many  morbid  conditions,  es- 
pecially dyspeptic  states  and  in  fevers,  and  is  usually  associated  with  loss 


502  MEDICAL  DIAGNOSIS. 

of  appetite;  yet  there  are  healthy  individuals  with  good  appetite  whose 
tongue  is  constantly  furred.  A  coated  tongue  is  present  in  acute  and 
chronic  gastric  catarrh,  while  on  the  other  hand  gastric  ulcer  is  very  often 
accompanied  by  a  clean  tongue  and  good  appetite.  The  coating  or  fur  is 
composed  of  accumulated  epithelium  and  food  detritus  and  contains  great 
numbers  of  micro-organisms.  The  immediate  cause  of  the  extraordinary 
proliferation  and  accumulation  of  epithelial  elements  is  not  well  understood. 
That  the  absence  of  coating  is  not  merely  dependent  upon  mechanical  con- 
ditions associated  with  drinking  and  the  ingestion  of  food  is  clearly  shown 
by  clinical  experience.  The  coating  of  the  tongue  like  its  mucous  membrane 
is  very  often  stained  by  articles  of  food  and  drink  or  by  drugs. 

Coating  of  the  Tongue  in  Local  and  General  Conditions. — (a)  Local- 
ized coating  of  the  tongue  results  from  the  irritation  of  a  tooth  and  sur- 
rounds traumatic  and  other  circumscribed  lesions. 

(b)  Unilateral  coating  of  the  tongue  is  sometimes  seen  in  trifacial 
neuralgia  involving  the  infra-orbital  branch.  It  may  occur  also  in  uni- 
lateral palsy  of  the  tongue. 

(c)  A  uniform  thin,  whitish  coating  is  habitual  to  many  persons 
in  health,  especially  mouth-breathers,  smokers,  and  those  who  are  troubled 
by  subacute  catarrhal  processes  involving  the  pharynx  and  stomach.  It 
occurs  also  in  constitutional  disturbances  attended  by  slight  fever. 

(d)  A  thickish,  pasty,  yellow-white  fur  is  common  in  those  ad- 
dicted to  excesses  at  table  or  in  tobacco  or  alcohol.  It  is  attended  with  a 
disagreeable  taste.  On  rising  it  usually  involves  the  greater  portion  of  the 
dorsum  of  the  tongue,  but  disappears  in  part  or  wholly  during  the  day. 
In  many  persons  this  coating  remains  upon  the  back  part  of  the  tongue 
continuously.  Its  disappearance  is  to  some  extent  due  to  movements  of 
the  tongue,  friction  against  the  teeth,  the  mechanical  effects  of  food  and 
drink,  and  increased  flow  of  salivary  and  buccal  secretions.  A  slightly 
enlarged,  flabby,  indented  tongue  covered  with  fur  of  this  kind  very  often 
accompanies  chronic  gastritis. 

(e)  A  thick,  uniform,  moist,  whitish  or  yellowish-white  coating 
with  abrupt  edges  is  seen  in  the  early  stages  of  the  acute  febrile  diseases. 
In  consequence  of  the  diminished  amount  and  altered  character  of  the 
salivary  and  buccal  secretions,  this  coating  presently  loses  its  moisture 
and  becomes  dry  and  darker  in  color.  After  a  time  it  separates,  leaving 
the  tongue  moist  and  of  normal  appearance  if  convalescence  has  begun, 
or  dry,  hard,  red  or  brown,  and  denuded  of  epithelium  if  the  fever  con- 
tinues and  particularly  if  the  patient  falls  into  the  so-called  typhoid  condi- 
tion. Under  these  circumstances  the  tongue  becomes  fissured  both  longi- 
tudinally and  transversely.  In  some  cases  a  deep  median  fissure  forms, 
on  each  side  of  which  there  is  a  thick,  rough,  dry,  brownish  fur,  the  tip  and 
edges  of  the  tongue  being  red  and  denuded;  or  again  the  tongue  may  be 
dry,  red,  and  glazed.  It  is  protruded  upon  request  tremulously  and  slowly 
and,  owing  to  the  accompanying  mental  condition,  is  not  immediately 
withdrawn.  The  disappearance  of  the  crusty  coating,  the  redevelopment 
of  epithelium,  and  the  return  of  moisture  are  favorable  signs.  The  tongue 
may  be  dry,  brown,  and  incrusted  in  the  last  stages  of  chronic  diseases  of 
the  nervous  system,  and  in  cancer,  nephritis,  and  pulmonary  tuberculosis. 


SYMPTOMS  AND  SIGNS  :   TONGUE.  503 

(f)  The  thick  white  fur  of  the  acute  febrile  diseases  is  sometimes 
penetrated  by  the  greatly  enlarged  filiform  papilla?  which  appear  as  scat- 
tered bright  red  minute  points.  This  constitutes  one  of  the  forms  of  so- 
called  "strawberry  tongue."  It  occurs  with  some  frequency  in  scarlet 
fever,  but  is  not  diagnostic  of  that  disease,  since  it  may  be  present  in 
other  acute  febrile  infections. 

(g)  A  dense,  white,  flaky  coating  is  sometimes  seen  upon  the 
tongue  of  patients  who  are  fed  upon  an  exclusive  milk  diet.  A  somewhat 
similar  appearance  may  be  presented  by  children  suffering  from  thrush — 
a  condition  caused  by  saccharomyces  albicans,  which  begins  on  the  tongue 
in  the  form  of  slightly  elevated  pearly  white  spots  which,  by  increase  in 
size  and  coalescence,  may  cover  the  greater  part  of  the  dorsum  of  the 
tongue. 

(h)  General  hypertrophy  of  the  papill.e  gives  rise  to  a  peculiar 
appearance  which  suggests  coarse  plush.  This  is  the  shaggy  tongue.  It  is 
seen  in  gastro-intestinal  and  constitutional  diseases  in  advanced  life,  but  is 
sometimes  present  in  elderly  people  whose  health  is  good.  The  shaggy 
tongue  is  frequently  also  fissured,  the  plush-like  surface  being  divided  by 
conspicuous  deep  longitudinal  and  transverse  lines  of  separation.  The 
color  is  usually  deep  red.  Upon  the  supervention  of  acute  illness  it  quickly 
becomes  dry,  hard,  and  full,  usually  remaining  rough. 

A  red,  dry  tongue,  denuded  of  epithelium,  glistening  and  resembling 
raw  beef — the  beefy  tongue — occurs  in  dysentery  and  chronic  intestinal 
catarrh.    It  is  seen  also  in  hepatic  abscess. 

Other  conditions  of  the  tongue  may  be  of  diagnostic  importance: 
fissures,  ulcers,  mucous  patches  and  plaques,  tumors,  and  cicatrices. 

(a)  Fissures  of  the  tongue  are  often  seen  in  healthy  persons  in  ad- 
vanced life.  They  may  be  the  signs  of  a  superficial  chronic  glossitis  caused 
by  habitual  use  of  tobacco  or  irritating  food  or  drink.  The  median  longi- 
tudinal fissure  is  commonly  the  most  marked  and  readily  becomes  ulcer- 
ated. Transverse  fissures  are  common.  Sometimes  the  fissures  are  forked 
or  curved.  Fissures  may  be  deep  and  inflamed,  the  result  of  extending 
glossitis — dissecting  glossitis — or  syphilis.  Fissures  are  common  in  chronic 
hepatic  disease,  chronic  colitis,  and  diabetes  mellitus.  Local  fissures  or 
notches  at  the  edge  of  the  tongue  may  arise  from  the  irritation  of  a  broken 
or  carious  tooth  or  from  syphilitic  ulceration. 

(b)  Ulcers  op  the  Tongue.—  Simple  excoriations  occur  as  the  result  of 
slight  traumatism  or  scalding,  or  spontaneously  in  dyspeptic  conditions. 
Aphthous  stomatitis  is  characterized  by  small,  slightly  depressed  spots 
with  grayish  bases  and  bright  red  margins.  They  occur  at  the  edges  and 
tip  of  the  tongue,  on  the  frsenum,  and  elsewhere  about  t he  mucous  mem- 
brane of  the  lips  and  mouth.  The  ulcers  are  preceded  by  vesicles  and  are 
attended  with  great  pain.  The  buccal  secretions  are  increased.  The  ulcers 
may  appear  singly  or  in  series  or  crops.  They  occur  in  transient  gastric 
derangements  and  in  women  at  the  menstrual  period.  There  is  an  indi- 
vidual predisposition  to  them. 

A  chronic,  recurrent  herpetic  eruption  of  the  buccal  mucous  mem- 
brane, sometimes  associated  with  erythema  multiforme,  has  been  observed 
in  neurotic  persons. 


504  MEDICAL  DIAGNOSIS. 

Riga's  disease  is  an  affection  occurring  about  the  time  of  the  first 
dentition  and  characterized  by  a  pearly  white  pseudomembrane  beneath 
the  tongue  and  upon  the  frsenum,  with  induration  and  ulceration.  It  is 
endemic  and  sometimes  epidemic  in  Southern  Italy. 

Superficial  ulcers  with  a  red  glazed  surface  occur  upon  the  tongue  in 
various  forms  of  chronic  glossitis.  They  are  of  irregularly  round  or  oval 
shape  with  infiltrated  edges  and  are  usually  extremely  painful.  Ulceration 
of  the  tongue  is  commonly  attended  with  salivation.  Tuberculosis  of  the 
tongue  shows  itself  in  the  form  of  circumscribed,  indolent,  irregularly 
extending  ulceration  with  a  necrotic  or  caseous  base.  The  edges  are  usually 
slightly  infiltrated  but  sharply  defined.  This  ulcer  is  extremely  painful 
upon  contact  and  is  sometimes  attended  by  salivation.  The  lesions  may 
be  single  or  multiple  and  are  usually  secondary  to  tuberculous  disease  of 
the  lungs.  The  glands  at  the  angle  of  the  jaw  are  not  usually  enlarged. 
Syphilis  is  a  common  cause  of  ulceration  of  the  tongue.  In  secondary 
syphilis  superficial  and  linear  ulcers  are  common  at  the  border  of  the 
tongue  as  the  result  of  the  irritation  of  the  teeth.  A  single  ulcer  with  an 
indurated  base  and  enlargement  of  the  cervical  glands  may  be  the  initial 
lesion  of  syphilis.  A  mucous  patch  may  undergo  ulceration,  and  in  later 
syphilis  a  gumma  may  become  necrotic,  forming  a  deep  foul  ulcer.  In 
some  instances  difficulty  attends  the  differential  diagnosis  of  a  single 
ulcer,  which  may  be  due  to  tuberculosis,  syphilis,  or  malignant  disease. 
The  resemblances  upon  inspection  and  palpation  may  be  very  close. 
In  the  first  there  are  usually  evidences  of  tuberculosis  of  the  larynx  or 
lungs  and  the  presence  of  tubercle  bacilli  in  the  scrapings.  In  cases  not 
otherwise  to  be  determined  inoculation  experiments  should  be  performed. 
In  the  initial  lesion  of  syphilis  the  induration  is  dense  and  circumscribed. 
The  age  and  habits  of  the  patient  are  to  be  taken  into  consideration.  Great 
enlargement  and  tenderness  of  the  lymphatics  of  the  neck  constitute  im- 
portant symptoms.  The  evolution  of  the  process  and  the  development  of 
mucous  patches,  cutaneous  rashes,  fever,  and  the  like  make  the  diagnosis 
clear.  In  gummatous  ulceration  the  enlarged  surface  is  greater  and  the 
infiltration  less  dense.  The  therapeutic  test  is  important;  the  ulcer  heals 
under  antisyphilitic  treatment.  A  carefully  taken  clinical  history  sheds 
light  upon  a  doubtful  case.  In  epithelioma  of  the  tongue  the  diagnosis 
may  be  reached  by  exclusion.  The  process  tends  to  spread,  the  sub- 
lingual lymphatics  become  involved,  the  ulcer  is  foul  and  indolent,  and 
the  patient  is  almost  always  past  middle  age. 

The  ulcer  frequently  observed  on  the  frsenum  of  the  tongue  in  whoop- 
ing-cough is  traumatic.  It  results  from  the  violent  impact  of  the  under 
surface  of  the  tongue  against  the  sharp  lower  incisors  during  the 
paroxysm. 

(c)  Mucous  Patches  and  Plaques.  —  The  multiple  grayish-white 
superficial  lesions  of  syphilis  known  as  mucous  patches  occur  upon  the 
tongue  as  well  as  upon  the  soft  palate,  cheeks,  and  lips.  A  slightly 
raised,  smooth,  red,  oval-shaped  area  sometimes  seen  in  the  middle  of 
the  dorsum  of  the  tongue  in  pipe  smokers  is  known  as  the  smoker's 
patch.  The  surface  is  smooth  and  sometimes  white  or  pearly  white  in 
appearance. 


SYMPTOMS  AND  SIGNS  :   TONGUE.  505 

Xanthelasma  occasionally  appears  upon  the  sides  of  the  tongue  in  the 
form  of  yellowish,  soft,  slightly  raised,  oblong  patches.  It  occurs  in  vari- 
ous conditions  but  is  noticeably  frequent  in  chronic  jaundice  and  diabetes. 

Leucoplakia  is  a  condition  characterized  by  the  development  of  irreg- 
ular white  or  pearly-white  smooth  patches  upon  the  tongue  which  show 
no  tendency  to  ulcerate.  They  are  hard  to  the  touch  and  gradually 
extend,  sometimes  becoming  papillomatous.  These  patches  may  be  the 
starting-point  of  epithelioma.  The  condition  is  described  under  various 
terms,  as  buccal  psoriasis,  ichthyosis  and  keratosis  mucosae  oris.  They 
present  some  points  of  similarity  to  the  lesions  of  syphilitic  glossitis, 
which  is,  however,  more  common  at  the  edge  and  tip  of  the  tongue  than 
on  the  dorsum  and  yields  to  antisyphilitic  medication. 

Eczema  of  the  Tongue — Geographical  Tongue. — This  condition  is  char- 
acterized by  the  formation  of  irregularly  annular  patches  upon  the  tongue. 
There  is  desquamation  of  the  epithelium.  The  process  is  attended  with 
burning  and  itching.  The  patches  extend  at  the  margins  with  new  forma- 
tion of  epithelium  in  the  centre.  The  borders  are  slightly  red  and  well 
defined  but  without  induration.  The  condition  is  more  common  in  infants 
and  children  than  in  adults.    The  process  is  recurrent  and  protracted. 

(d)  Tumors  of  the  Tongue. — Solid  tumors  of  the  tongue  are  usually 
tuberculous  or  syphilitic.  They  invade  the  substance  of  the  organ,  usually 
presenting  toward  its  dorsal  surface.  Tuberculous  nodules  break  down, 
promptly  giving  rise  to  an  indolent  ulceration  with  caseation.  Gummata 
rapidly  undergo  extensive  necrosis  but  yield  to  treatment.  Retention 
cysts  occur  in  connection  with  the  tongue.  Ranula  is  the  most  common; 
it  is  due  to  an  obstruction  and  dilatation  of  a  duct  of  the  sublingual  or 
submaxillary  glands.  Mucous  cysts  also  occur.  Echinococcus  cysts, 
which  develop  as  a  rule  by  preference  in  highly  vascular  structures,  are  rare 
in  the  tongue.  Carcinoma  is  much  more  common  in  men  than  in  women 
and  extremely  malignant.    Sarcoma  is  comparatively  rare. 

(e)  Cicatrices.  —  Scars  upon  the  tongue  tell  the  tale  of  former 
traumatism,  as  the  accidental  biting  of  the  tongue,  a  fall  or  blow  upon 
the  chin  when  the  tongue  is  between  the  teeth,  or  the  grinding  of  the 
teeth  during  the  clonic  convulsions  of  epilepsy.  They  may  be  the  indica- 
tions of  former  active  diseases,  especially  syphilis.  Sclerosis  of  the  tongue 
with  local  deformity  is  a  common  result  of  the  healing  of  gummatous 
ulceration. 

The  buccal  mucous  membrane  is  commonly  implicated  in  infections 
involving  the  other  organs  of  the  mouth,  especially  the  various  forms  of 
stomatitis.  It  is  very  often  the  starting-point  of  the  progressive  gangre- 
nous affection  known  as  noma  or  cancrum  oris. 


506  MEDICAL  DIAGNOSIS. 


VIII. 

THE  DIGESTIVE  SYSTEM  (CONTINUED):     THE  PALATE: 
TONSILS;   PHARYNX. 

The  passage  from  the  mouth  to  the  oesophagus  by  way  of  the  pharynx 
is  called  the  fauces  or  isthmus  faucium.  It  is  bounded  above  by  the  soft 
palate,  laterally  by  the  palatine  arches  and  tonsils,  and  below  by  the  base 
of  the  tongue.  These  structures  are  covered  with  mucous  membrane  con- 
tinuous with  that  of  the  mouth. and  are  liable  to  the  same  morbid  processes. 
An  inspection  of  these  parts  yields  information  of  importance  in  the  diag- 
nosis of  local  and  constitutional  disease.  Infection  may  take  place  di- 
rectly or  by  extension  from  the  mouth  and  nasopharynx.  Forms  of  angina 
— simplex,  follicular,  suppurative,  and  diphtheritic — result.  When  the 
tonsils  are  principally  or  alone  involved  the  condition  is  spoken  of  as 
tonsillitis.  The  underlying  muscular  structures  may  be  involved  by 
extension.  The  tonsils  and  adjacent  lymph  structures  are  points  of  inva- 
sion for  the  infecting  agents  in  rheumatism  and  other  affections.  There  are 
forms  of  acute  tonsillitis  that  are  essentially  rheumatic.  In  children  the 
articular  manifestations  of  rheumatic  fever  and  chorea  frequently  show  a 
definite  relationship  to  tonsillitis  and  the  latter  affection  is  not  rarely 
followed  by  endocarditis  and  chorea.  The  tonsils  may  be  the  port  of 
invasion  for  tuberculosis  or  the  seat  of  tuberculous  lesions. 

Subacute  and  chronic  pharyngeal  inflammation  may  be  secondary 
to  gastric  disorders  or  to  the  gouty  diathesis.  The  pharynx  is  sometimes 
involved  in  rheumatism.  Paralysis  of  the  soft  palate  and  spasm  and 
paralysis  of  the  pharynx  occur.  Superficial  ulceration  of  the  pharynx 
is  very  common  in  advanced  pulmonary  tuberculosis. 

General  redness  of  the  faucial  mucous  membrane  occurs  in  simple 
inflammations  and  in  many  of  the  specific  febrile  affections,  as  rotheln, 
the  variolous  diseases,  influenza,  and  erysipelas.  In  the  exanthemata, 
especially  measles,  scarlatina,  varicella,  and  variola,  there  are  efflorescences 
corresponding  to  the  cutaneous  eruptions.  In  these  situations  the  pocks 
of  varicella  and  variola,  owing  to  the  action  of  warmth  and  moisture, 
lose  their  roof  in  the  vesicular  stage  and  are  converted  into  small  cir- 
cular or  oval  superficial  ulcerations  with  purulent  or  necrotic  bases  and 
a  more  or  less  marked  areola.  Redness  of  the  mucous  membrane  in  this 
region  is  a  symptom  of  chronic  gastritis  or  the  action  of  certain  drugs,  as 
the  iodine  compounds  and  belladonna,  and  of  corrosive  poisons. 

Hemorrhage  occurs  into  the  mucous  membrane  in  the  form  of  petech- 
ise,  infarcts,  and  extravasations,  and  there  is  bleeding  from  these  surfaces 
in  general  hemorrhagic  states.  These  tissues  are  pallid  in  the  anaemias, 
yellow  in  jaundice,  and  show  a  bluish  tint  in  cyanosis.  The  mucous 
patches  of  syphilis  may  be  seen. 

Pain  is  a  prominent  symptom  in  angina,  especially  in  the  acute  forms. 
It  may  be  spontaneous,  but  is  excited  by  the  movements  of  deglutition 
and  by  contact  of  articles  of  food  and  drink  with  ulcerated  surfaces.     Pair 


SYMPTOMS  AND  SIGNS  :   PALATE.  507 

and  tickling  referred  to  the  pharynx  may  be  symptomatic  of  acute  rhini- 
tis. These  symptoms  are  common  in  hay  fever.  Sensations  of  dryness 
and  tickling  accompanied  by  the  inclination  to  hawk  and  clear  the  throat 
are  constant  symptoms  of  pharyngitis.  Annoying  hawking  is  especially 
•excited  by  disease  of  the  nasopharynx. 

Dysphagia  is  common.  It  varies  in  degree  and  may  be  due  to  pain  or 
to  mechanical  obstruction.  When  dysphagia  is  marked  both  these  causes 
are  commonly  operative.  In  suppurative  tonsillitis  and  retropharyngeal 
abscess  dysphagia  may  be  complete.  It  is  a  symptom  of  the  various  forms 
of  stomatitis  and  glossitis  as  well  as  of  tonsillitis  and  pharyngitis.  Painful 
•dysphagia  referred  to  the  pharynx  is  a  common  symptom  in  cases  showing 
no  signs  of  inflammation  of  the  mucous  membrane — rheumatic  pharyngitis. 
The  angina  which  attends  diphtheria,  scarlet  fever,  measles,  varicella,  and 
variola  is  accompanied  by  dysphagia  which  is  often  distressing. 

Dyspncea  may  become  an  important  symptom  in  suppurative  tonsil- 
litis, retropharyngeal  abscess,  and  erysipelas  extending  to  the  pharynx. 

Chronic  interference  with  respiration  accompanied  by  mouth-breath- 
ing results  from  hyperplasia  of  the  tonsils  and  especially  from  hyperplasia 
of  the  pharyngeal  tonsil — adenoid  vegetations.  In  severe  acute  angina  and 
in  certain  chronic  diseases  involving  the  tonsils  and  pharynx,  as  cancer 
and  forms  of  syphilis,  the  drainage  of  the  fauces  is  interfered  with  and  the 
accumulating  secretions  and  exudates  undergo  decomposition.  The  odor 
of  the  breath  may  be  intense,  fetid,  and  disgusting.  Accumulations  of 
epithelial  cells,  leucocytes,  and  bacteria  in  the  tonsillar  crypts  are  very 
common  in  chronic  lacunar  tonsillitis  and  in  individuals  presenting  no 
other  symptoms  of  disease  of  the  throat.  They  appear  as  small  white  or 
yellowish-white  concretions  which  sometimes  undergo  calcareous  changes. 
They  are  sometimes  expectorated  and  should  be  removed  by  the  curette. 
They  impart  a  disagreeable  odor  to  the  breath. 

THE  PALATE. 

Developmental  deformities  do  not  fall  within  the  scope  of  this  work. 
A  narrow,  high,  arched  palate  is  regarded  as  among  the  stigmata  of  degen- 
eration. Circumscribed  ulceration  of  the  mucous  membrane  of  the  hard 
palate  is  frequently  met  with  in  the  new-born  or  may  be  caused  in  artifi- 
cially-fed children  by  the  irritation  of  the  rubber  nipple.  The  ulceration 
thus  caused  is  sometimes  described  under  the  term  Bednar's  aphtha.  In 
young  children  patches  of  thrush  are  not  uncommon  upon  the  hard  palate. 
Ali-coss  formation  attended  with  great  pain  occasionally  involves  the 
mucous  membrane  of  the  hard  palate  in  connection  with  alveolar  disease. 
Perforations  occur  as  the  result  of  syphilis. 

The  soft  palate  in  health  is  freely  movable  and  symmetrical.  The 
form  of  the  uvula  varies  in  different  persons.  As  a  result  of  defective 
development  it  is  sometimes  bifid.  It  may  be  attached  laterally  to  the 
sofl  palate  or  tonsil  or  to  the  posterior  wall  of  the  pharynx  in  consequence 
of  adhesive  inflammation  in  diphtheria  or  syphilis.  Perforation  of  the 
soft  palate  is  almost  always  the  result  of  syphilis.  In  very  rare  instances 
it  has  followed  scarlet  fever.     The  uvula   varies  in   length  normally.     It 


508  MEDICAL  DIAGNOSIS. 

frequently  becomes  elongated  in  angina  and  bronchitis.  Under  these 
circumstances  it  causes  irritation  of  the  base  of  the  tongue  and  excites 
cough,  especially  in  the  recumbent  posture;  the  mechanical  violence  of 
intense  paroxysmal  cough  elongates  the  uvula  and  thus  a  vicious  circuit 
is  established.  It  becomes  elongated  and  cedematous  in  cases  of  debility, 
anaemia,  and  anasarca.  When  greatly  cedematous  the  uvula  becomes 
globular  and  may  attain  the  size  of  a  cherry,  interfering  with  swallowing 
and  breathing  and  producing  a  constant  disposition  to  hawk.  In  consti- 
tutional hemorrhagic  states  submucous  extravasation  of  blood  may  occur 
in  the  uvula.  In  very  rare  instances  crops  of  vesicles  resembling  herpes 
show  themselves  upon  the  palate. 

Anaesthesia  of  the  hard  and  soft  palate  and  of  the  anterior  two-thirds 
of  the  tongue  occurs  in  lesions  of  the  sensory  division  of  the  fifth  nerve. 
The  tactile  sense  is  usually  lost  before  the  pain.  The  palate  is  innervated 
by  the  accessory  nerve  to  the  vagus.  Paralysis  of  the  soft  palate  occurs  in 
bulbar  palsy,  basal  tumors,  and  meningitis  of  the  base.  By  far  the  most 
common  cause  is  postdiphtheritic  neuritis.  Upon  inspection  while  the 
patient  pronounces  the  long  a  the  palate  and  uvula  are  thrown  back  and 
elevated.  Under  normal  circumstances  the  extent  of  this  movement  is 
the  same  on  both  sides.  In  unilateral  paralysis  movement  upon  the  af- 
fected side  is  greatly  diminished.  In  bilateral  paralysis  the  whole  palate 
remains  relaxed  and  motionless,  the  voice  has  a  nasal  character,  the  pro- 
nunciation of  certain  consonants — gutturals — is  impaired,  and  upon  attempts 
to  swallow,  liquids  are  returned  through  the  nose.  Lesions  involving  the 
nerve-supply  of  one  side  cause  unilateral  paralysis. 

THE  TONSILS. 

The  tonsils,  also  called  amygdalae  from  their  almond  shape,  lie  at  the 
side  of  the  pharynx  between  the  anterior  and  posterior  palatine  folds. 
They  are  larger  in  childhood  than  in  adult  life  and  early  undergo  senile 
involution.  The  greater  part  of  their  surface  is  exposed  to  inspection  by 
ordinary  methods.  Upon  gagging  they  are  rotated  forward.  In  inflamma- 
tion the  mucosa  is  reddened  and  swollen  and  the  surface  covered  with  a 
mucoid  or  mucopurulent  'secretion  which  may  be  tinged  with  blood.  In 
follicular  or  lacunar  tonsillitis  this  secretion  develops  in  the  crypts,  pro- 
ducing whitish-yellow  spots.  These  may  by  extension  and  coalescence 
form  patches  upon  the  tcnsils  presenting  a  superficial  resemblance  to  diph- 
theria. The  pseudomembrane  thus  formed  is  not  usually  distinctly  mar- 
ginate  and  corresponds  in  appearance  to  the  points  of  exudate  seen  to 
occupy  adjacent  crypts.  It  is  not  developed  in  the  mucosa  but  lies  upon  it, 
as  may  be  seen  upon  removing  it  by  wiping  or  gentle  scraping.  A  pseudo- 
membranous exudate  frequently  forms  in  the  course  of  various  infections, 
as  scarlet  fever,  measles,  pertussis,  enteric  fever,  and  variola.  In  a  great 
majority  of  these  cases  the  Streptococcus  pyogenes  is  the  active  organism. 
As  a  rule  the  development  of  this  form  of  pseudomembrane  does  not 
constitute  a  serious  complication  of  the  primary  disease.  It  may,  how- 
ever, give  rise  to  an  intense  angina  with  local  sloughing  and  grave  con- 
stitutional disturbance.     A  general  streptococcus  infection  is  by  no  means 


SYMPTOMS  AND  SIGNS  :    PHARYNX.  509 

infrequent.  A  pseudomembranous  exudate  occurs  in  its  most  typical  form 
as  a  manifestation  of  diphtheria.    It  is  caused  by  the  Klebs-Loffler  bacillus. 

In  suppurative  tonsillitis  or  quinsy  one  or  both  tonsils  may  be  in- 
volved. The  earliest  symptoms  are  those  of  an  ordinary  acute  angina — 
pain,  dryness,  dysphagia,  with  fever  and  other  symptoms  of  constitutional 
disturbance.  The  tonsils  are  enlarged,  dusky  red,  and  cedematous.  They 
may  even  meet,  or  if  one  only  is  involved  it  may  extend  some  distance 
beyond  the  median  line.  In  many  instances  there  is  salivation.  The  breath 
is  foul,  the  glands  of  the  neck  enlarged,  and  the  patient  opens  his  mouth 
only  partially  and  with  great  difficulty.  After  suppuration  occurs  fluctua- 
tion may  be  felt. 

Enlargement  of  the  tonsils  is  common  in  children.  It  may  be  due  to 
repeated  attacks  of  acute  tonsillitis  or  to  a  chronic  inflammatory  process 
leading  to  a  hyperplasia  of  the  lymphoid  elements.  The  tonsillar  crypts 
are  enlarged.  In  some  cases  a  probe  may  be  introduced  to  the  depth  of  a 
centimetre  or  more.  Partial  or  complete  adhesions  of  the  anterior  pillars 
to  the  tonsils  are  seen,  and  these  structures  are  sometimes  thin,  red,  and 
stretched  by  the  enlargement  of  the  tonsil.  In  some  instances  the  tonsils 
are  dense  and  firm,  the  connective-tissue  stroma  predominating.  Enlarge- 
ment of  the  tonsils  is  very  often  associated  with  adenoid  vegetations  in 
the  pharyngeal  vault.  Mouth-breathing  and  its  concomitant  derange- 
ments accompany  this  condition.  Ulceration  of  the  tonsils  is  not  very 
common.  In  syphilis  the  primary  chancre  has  occurred  upon  the  tonsils. 
In  secondary  syphilis  mucous  patches  are  very  common  in  this  region,  and 
in  the  tertiary  stage  gumma  may  give  rise  to  enlargement  of  the  tonsil 
and,  upon  breaking  down,  result  in  deep  circular  ulceration  with  a  necrotic 
base  and  little  hyperaemia  of  the  surrounding  tissue.  Tuberculous  ulcera- 
tion of  the  tonsils  is  not  common. 

THE  PHARYNX, 

This  organ  may  be  divided  into  an  upper  portion — the  nasopharynx — 
and  a  lower  portion — the  oropharynx.  The  former  may  be  examined  by 
palpation  with  the  finger  or  by  the  rhinoscopic  mirror;  the  latter  by  direct 
inspection  in  a  good  light.  Small  foreign  bodies,  as  fish-bones  or  a  beard 
of  wheat,  may  be  recognized  upon  inspection;  larger  foreign  bodies,  as  an 
artificial  denture  or  fragment  of  meat  or  bone,  by  inspection  or  palpation. 
The  presence  of  adenoid  vegetations  due  to  hyperplasia  of  the  pharyngeal 
tonsil  may  be  thus  determined.  Papillomatous  masses  sometimes  fill  the 
vault  of  the  pharynx,  extending  into  the  posterior  nares  and  greatly  inter- 
fering with  respiration.  By  occluding  the  orifices  of  the  Eustachian  tubes 
they  cause  deafness  and  middle-ear  disease. 

Cyanosis  and  Pulsation. — Cyanosis  of  the  pharyngeal  mucosa  may 
result  from  general  derangements  of  the  circulation  or  respiration  or  from 
local  causes,  as  obstruction  to  the  return  flow  of  the  blood  by  way  of  the 
superior  vena  cava,  from  aneurism  or  from  mediastinal  tumor.  In  aortic 
regurgitation  pulsation  of  the  capillary  vessels  may  be  seen  or  unilateral 
pulsation  may  be  the  manifestation  of  a  tortuous  internal  carotid  artery 
or  aneurism  of  that  vessel.    In  the  oozing  that  takes  place  from  the  pharynx 


510  MEDICAL  DIAGNOSIS. 

in  intense  congestion  or  hemorrhagic  states  the  blood  may  be  swallowed 
and  accumulate  in  the  stomach.  If  vomited  the  hemorrhage  may  be 
attributed  to  a  lesion  of  the  stomach.  This  error  of  diagnosis  may  be 
avoided  by  careful  inspection  of  the  pharynx. 

Pharyngitis.— In  acute  inflammation  of  the  oropharynx  the  mucosa 
is  congested  and  reddened.  The  patient  complains  of  tickling  and  dryness 
with  a  constant  desire  to  hawk.  The  secretions  are  diminished  and  al- 
tered. There  is  dryness  with  thin  flakes  or  a  whitish  exudate,  to  be  seen 
only  upon  close  examination.     The  constitutional  symptoms  are  slight. 

Rheumatic  angina  is  characterized  by  sore  throat  and  dysphagia 
referred  to  the  pharynx.  In  the  majority  of  the  cases  the  signs  upon  in- 
spection are  not  distinctive. 

Chronic  pharyngitis  may  develop  insidiously  or  as  the  result  of  re- 
peated acute  attacks.  The  mucosa  is  at  first  reddened  and  shows  dis- 
tended vesicles;  later  it  is  relaxed  and  presents  a  granular  or  warty  appear- 
ance— granular  pharyngitis,  due  to  hyperplasia  of  the  lymph  elements. 
The  secretion  is  mucoid  or  purulent  and  undergoes  desiccation,  forming 
dry  crusts  or  scales  which  very  often  communicate  an  offensive  odor  to  the 
breath.  The  process  extends  into  the  nasopharynx.  There  is  very  often 
a  free  mucoid  or  mucopurulent  secretion  which  gives  rise  to  the  sensation 
of  dropping  or  trickling  into  the  throat  and  causes  hawking.  In  other 
cases  the  secretion  is  slight  and  the  mucous  membrane  reddish-brown,  dry, 
atrophic,  smooth  and  glistening — pharyngitis  sicca.  The  pseudomembra- 
nous exudate  of  diphtheria  frequently  extends  into  the  pharynx;  the  exudate 
of  pseudodiphtheritic,  diphtheroid,  or  diplococcus  inflammation  commonly 
appears  upon  the  tonsils  and  does  not  as  a  rule  involve  the  pharynx. 

Ulceration  of  the  pharyngeal  wall  is  not  uncommon.  Limited  areas  of 
superficial  ulceration  occur  in  chronic  pharyngitis.  Small  round  or  oval 
ulcers  upon  the  posterior  wall  are  sometimes  seen  in  enteric  fever.  Irregu- 
lar superficial  patches  of  ulceration  are  frequently  seen  in  the  later  stages 
of  consumption.  The  bases  are  necrotic  and  grayish-yellow.  The  ulcera- 
tion may  involve  the  greater  part  of  the  posterior  pharyngeal  wall  and 
cause  intensely  painful  dysphagia.  Ulceration  of  the  pharyngeal  wall 
occurs  also  in  syphilis.  In  the  secondary  stage  it  is  very  often  superficial 
and  associated  with  mucdus  patches.  In  the  tertiary  stage  it  results  from 
the  breaking  down  of  gummata  which  heal  satisfactorily  under  treatment, 
leaving  white  cicatrices. 

Ulceration  of  the  pharynx  may  occur  in  connection  with  the  various 
forms  of  pseudomembranous  inflammation  and  attends  cancer  and  lupus. 
The  etiological  diagnosis  of  ulceration  of  the  pharynx  is  frequently  attended 
with  difficulty.  As  in  the  case  of  the  tongue,  tubercle,  cancer,  and  syphilis 
are  to  be  differentiated.  A  careful  anamnesis  is  important.  The  asso- 
ciated clinical  phenomena  are  very  often  characteristic.  In  tuberculosis 
the  presence  or  absence  of  tubercle  bacilli  and  the  inoculation  test  are 
important;  in  syphilis  the  therapeutic  test. 

Acute  phlegmonous  inflammation  of  the  pharynx  may  result  from 
traumatism  or  foreign  bodies  in  the  pharynx. 

Acute  infectious  phlegmon,  a  rare  condition,  characterized  by  anginal 
symptoms,  dysphagia,  rapid  abscess  formation,  swelling  of  the  neck,  and 


SYMPTOMS  AND  SIGNS  :    (ESOPHAGUS.  oil 

severe   constitutional    symptoms,    may    result    from    direct    traumatism, 
the  injury  caused  by  foreign  bodies,   or  arise  spontaneously. 

Retropharyngeal  abscess  manifests  itself  upon  inspection  and  palpa- 
tion as  a  projecting  fluctuating  tumor  upon  the  posterior  wall  of  the  pharynx 
in  the  median  line.  Attendant  phenomena  are  restlessness,  dysphagia,  and 
changes  in  the  voice,  which  becomes  nasal  or  metallic  as  the  result  of  pres- 
sure. Retropharyngeal  abscess  is  a  rare  affection.  It  has  been  observed 
in  children  previously  in  apparent  good  health  as  a  sequel  of  the  infectious 
diseases,  particularly  scarlet  fever  and  diphtheria,  and  in  caries  of  the 
cervical  vertebra?. 

Angina  Ludovici :  Ludwig's  Angina  ;  Cellulitis  of  the  Neck. — A  rap- 
idly developing  phlegmonous  inflammation  of  the  tissues  about  the  floor  of 
the  mouth  is  described  under  these  names.  It  apparently  results  from 
trauma  or  some  lesion  about  the  roots  of  the  teeth  or  from  infection  of  the 
submaxillary  gland.  It  may  occur  as  the  result  of  secondary  infection  in 
the  specific  fevers,  particularly  diphtheria  and  scarlet  fever.  The  inflamma- 
tion is  the  result  of  streptococcus  infection.  Swelling  usually  appears  first 
in  the  submaxillary  region  of  one  side  and  rapidly  spreads,  with  diffuse 
dull  redness  and  brawny  induration  of  the  neck.  The  tendency  is  to  speedy 
suppuration  and  extensive  gangrene  with  general  septicaemia.  The  disease 
is  rare  and  very  fatal. 

The  innervation  of  the  pharynx  is  derived  from  the  pharyngeal  plexus, 
formed  by  the  combination  of  the  glossopharyngeal  and  branches  of  the  vagus. 

Spasm  of  the  pharynx  is  a  functional  disorder.  It  is  common  in  neuro- 
pathic individuals.  It  is  the  cause  of  ordinary  gagging  and  occurs  in  hydro- 
phobia and  as  a  convulsive  manifestation  of  hysteria — globus  hystericus. 

Motor  palsy  of  the  pharynx  occurs  in  postdiphtheritic  neuritis,  acute 
ascending  paralysis,  and  bulbar  paralysis.  It  may  result  from  lesions  at 
the  base  of  the  brain.  It  is  commonly  bilateral.  There  is  difficulty  in 
swallowing  and  food  is  not  properly  passed  into  the  oesophagus.  Particles 
of  food  may  pass  into  the  larynx  and,  when  there  is  associated  paralysis 
of  the  soft  palate,  into  the  posterior  nares.  Fluids  are  regurgitated 
through  the  nose.     In  unilateral  lesions  the  power  of  deglutition  remains. 

Anaesthesia  of  the  pharynx  is  produced  by  bromidism  and  the  local 
application  of  cocaine. 


IX. 

THE  DIGESTIVE  SYSTEM  (CONTINUED):  THE  (ESOPHAGUS. 

The  upper  limit  of  this  organ  is  about  at  the  level  of  the  cricoid  car- 
tilage and  opposite  the  sixth  cervical  vertebra.  It  terminates  in  the  car- 
diac orifice  of  the  stomach  opposite  the  upper  border  of  the  body  of  the 
eleventh  thoracic  vertebra.  It  has  a  short  infradiaphragmatic  course  of 
about  one  and  a  half  centimetres.  It  begins  about  six  inches — fifteen  cm. 
— from  the  incisor  teeth,  is  about  nine  and  a  half  inches — twenty-four  cm. 
— in  length,  and  varies  from  three-fourths  to  one  and  a  fourth  inch— two 
to  three  cm. — in  diameter,  the  narrowest    parts  being  at  the  commence- 


512  MEDICAL  DIAGNOSIS. 

ment,  in  the  middle,  where  it  is  crossed  by  the  left  primary  bronchus,  and 
at  its  point  of  entrance  into  the  stomach.  The  oesophagus  is  in  relation 
with  the  trachea,  the  left  bronchus,  the  thyroid  body,  the  peribronchial 
lymph-glands,  the  pneumogastric  and  recurrent  laryngeal  nerves,  the 
aorta,  the  azygos  vein,  the  thoracic  duct,  and  the  pericardium  and  pleurae. 
Nearly  its  whole  course  is  in  the  posterior  mediastinum. 

The  principal  methods  of  examination  are  auscultation,  direct  inspec- 
tion of  the  interior  of  the  oesophagus,  the  use  of  the  sound,  and  the  Ront- 
gen  rays.  Ordinary  inspection,  palpation,  and  percussion  are  of  no  prac- 
tical value,  although  the  first  two  of  these  methods  may  reveal  a  tumor 
upon  the  left  side  of  the  neck  when  there  is  a  diverticulum  or  new  growth  in 
the  cervical  portion. 

Auscultation.  —  Upon  auscultation,  the  stethoscope  being  placed  to 
the  left  of  the  ensiform  cartilage  or  to  the  left  of  the  spine  opposite  the 
tenth  rib,  a  gurgling  sound  may  be  heard  six  seconds  after  the  act  of  swal- 
lowing, as  determined  by  the  movement  of  the  larynx.  This  murmur  is 
due  to  the  propulsion  of  the  liquid  or  bolus  of  food  into  the  stomach  and 
is  not  to  be  confounded  with  the  sound  to  be  heard  over  the  cervical  part 
of  the  oesophagus  during  swallowing.  The  absence,  delay,  or  prolongation 
of  the  first-named  sound  is  evidence  of  obstruction  at  the  lower  end  of  the 
oesophagus. 

(Esophagoscopy.  —  Direct  inspection  may  be  practised  through  a 
suitable  tube  or  instrument  with  proper  illumination.  The  mucosa  in 
acute  inflammation  is  reddened,  swollen,  and  lax;  in  chronic  inflammation, 
grayish-white,  covered  with  a  viscid  mucus,  and  shows  dilated  veins.  The 
instrument  may  be  used  as  a  sound  to  determine  the  presence  or  absence 
of  dilatation  or  narrowing.  Ulceration,  new  growths,  and  cicatrices  may 
be  recognized,  and  fragments  of  ulcerated  tissue  have  been  removed  through 
the  cesophagoscope  for  examination.  Foreign  bodies  may  be  located  and 
have  been  removed  by  instruments  passed  through  the  tube  when  their 
removal  by  ordinary  methods  has  proved  impracticable. 

The  (Esophageal  Sound.  —  The  ordinary  rubber  tube  used  in  the 
examination  and  treatment  of  diseases  of  the  stomach  may  be  utilized  or 
oesophageal  bougies  especially  made  for  the  purpose.  The  latter  are  of 
whalebone  or  narrow  blades  of  metal  with  rounded  edges  and  provided 
with  adjustable  olive-shaped  tips  made  of  hard  rubber,  ivory,,  or  metal  and 
of  various  sizes.  The  sound  is  introduced  in  the  same  manner  as  the 
stomach  tube.  It  may  pass  directly  into  the  stomach  or  be  arrested  by 
some  obstruction.  The  location  of  the  stenosis  can  be  readily  deter- 
mined by  measuring  the  distance  from  the  teeth  upon  withdrawing 
the  instrument.  No  force  is  to  be  used.  Feeble  and  anaemic  patients 
may  faint  during  this  examination  and  neurotic  or  hysterical  indi- 
viduals may  have  local  spasm  or  even  general  convulsions.  Under 
such  circumstances  the  instrument  should  be  immediately  withdrawn. 
Sounding  must  be  performed  with  due  caution,  since  there  is  the 
danger  of  injury  or  perforation  of  the  wall  of  the  oesophagus,  the  rup- 
ture of  an  aneurism,  or  the  laceration  of  the  varicose  veins  of  the  oesopha- 
geal plexus  in  atrophic  cirrhosis.  By  the  use  of  the  sound  the  location  of 
strictures,   dilatations,  diverticula,   ulceration  or  at  least  areas  of  sensi- 


SYMPTOMS  AND  SIGNS:   (ESOPHAGUS.  513 

tiveness,  and  the  presence  or  absence  of  foreign  bodies  and  their  location 
may  be  learned.  The  careful  use  of  this  instrument  yields  information  as  to 
whether  or  not  a  stricture  is  dilatable  or  rigid  and  unyielding. 

The  X=rays. — The  presence  and  position  of  foreign  bodies  in  the 
oesophagus  may  be  ascertained  by  this  method  of  examination,  and  in 
appropriate  cases  information  in  regard  to  tumors  of,  or  in  relation  with, 
the  oesophagus.  The  possibility  that  a  large  atheromatous  plate  in  the 
aorta  may  be  mistaken  for  a  foreign  body  in  the  gullet  is  to  be  borne  in 
mind. 

Symptoms  of  disease  of  the  oesophagus  are  dysphagia,  pain,  and  the 
regurgitation  of  food. 

Dysphagia  varies  according  to  the  disease  and  its  site  and  is  com- 
monly greater  with  solids  than  with  fluids;  the  pain  may  be  sharply  local- 
ized or  diffuse;  the  regurgitation  of  food  may  be  partial  or  complete  and 
take  place  immediately  or  not  for  some  time. 

The  oesophagus  is  subject  to  developmental  defects,  of  which  the 
most  important  is  atresia.  Liquids  are  immediately  regurgitated  and  the 
sound  cannot  be  passed.  Death  results  from  inhalation  pneumonia  or 
starvation. 

Alterations  in  Calibre. — The  oesophagus  may  be  narrowed  or  dilated. 
Very  often  these  two  conditions  are  combined,  the  tube  being  narrowed 
at  one  point  and  dilated  at  another. 

Narrowing  may  be  intrinsic,  due  to  lesions  of  the  oesophagus  itself, 
as  congenital  defect,  stricture  from  inflammation,  cicatrix  or  neoplasm, 
or  muscular  spasm;  or  extrinsic,  due  to  pressure  from  without.  The 
symptoms  vary.  In  the  first  instance  they  are  chiefly  dysphagia,  pain,  and 
regurgitation;  in  the  second  there  are  superadded  to  these  the  symptoms 
of  the  disease  causing  the  compression.  Narrowing  may  be  a  congenital 
defect.  Its  position  in  this  easels  usually  at  the  upper  or  lower  extremity. 
The  chief  symptom  is  dysphagia. 

In  inflammatory  and  cicatricial  stenosis  there  is  a  history  of  accidental 
or  intentional  swallowing  of  a  caustic  or  corrosive  fluid,  or  the  history 
may  point  to  ulceration  as  the  result  of  traumatism  produced  by  a  foreign 
body,  softened  glands,  syphilis,  or  peptic  ulcer  at  the  cardia.  Ninety 
per  cent,  of  the  cases  of  stenosis  are  due  to  cancer,  which  acts  by  infil- 
trating the  walls  and  causing  the  development  of  contracting  connective 
tissue.  In  stricture  arising  from  cicatrix  the  dysphagia  comes  on  gradually 
and  is  progressive  and  permanent.  It  may  begin  abruptly  and  at  first  be 
caused  by  solids  only;  later  by  fluids.  Associated  spasm  may  cause  varia- 
tions in  degree,  but  there  are  no  intervals  of  complete  relief  as  in  spas- 
modic stricture.  The  bougie  is  always  arrested  at  the  same  distance  from 
the  teeth.  Food  is  regurgitated  shortly  after  it  is  taken  and,  unless  acid 
in  itself,  shows  an  alkaline  reaction.  Subjectively  it  seems  to  stop  at  or 
near  the  manubrium.  There  is  actual  progressive  starvation  and  cor- 
responding emaciation.  Signs  of  pressure  upon  the  recurrent  pharyngeal 
nerves  are  rare  in  cicatricial  stenosis. 

Malignant  stricture  of  the  oesophagus  is  commonly  carcinomatous. 
A  limited  number  of  cases  of  sarcoma  have  been  reported.  Carcinoma  is 
more  common  in  men  than  in  women.     It  is  rare  before  forty  and  most 

33 


514  MEDICAL  DIAGNOSIS. 

frequent  between  fifty  and  sixty.  It  occurs  with  about  equal  frequency 
in  the  upper  and  the  lower  half  of  the  organ.  The  symptoms  are  not 
very  different  from  those  of  cicatricial  stricture.  Pain  is  more  prominent; 
it  is  usually  referred  to  the  gullet;  sometimes  to  the  back  between  the 
shoulder-blades.  The  food  is  commonly  returned  shortly  after  it  is  taken 
and  is  sometimes  streaked  with  blood,  or  it  may  contain  fragments  of 
necrotic  tissue.  The  obstruction  may  become  complete  by  the  impaction 
of  food  in  the  stricture.  Cough  is  common,  and  hoarseness,  aphonia  or 
complete  loss  of  voice  may  result  from  involvement  of  the  recurrent  laryn- 
geal nerves.  Hunger,  at  first  urgent,  gives  place  to  indifference  to  food. 
Thirst  is  troublesome,  the  mouth  dry,  the  breath  foul,  and  hiccough  fre- 
quent.   The  progress  of  the  disease  is  rapid. 

Spasmodic  Stricture. — (Esophagismus  occurs  in  neurotic  persons  and 
especially  in  hysterical  women.  It  has  some  points  of  resemblance  to 
the  "globus  hystericus."  It  may  be  due  to  mental  shock  or  prolonged 
depressing  emotions,  but  it  is  more  frequently  due  to  reflex  irritation  in 
disorders  of  the  gastro-intestinal  or  reproductive  tract.  In  rare  instances 
it  accompanies  disease  of  the  larynx,  and  it  often  recurs  in  diseases  of 
the  oesophagus.  It  occurs  in  human  rabies  and  in  the  hysterical  counter- 
feits of  that  disease,  and  has  been  observed  in  cerebrospinal  fever,  tetanus, 
and  epilepsy.  Dysphagia  is  paroxysmal  and  of  varying  degree.  It  comes  on 
abruptly  and  often  passes  away  as  rapidly  as  it  came.  Food  is  regurgitated 
suddenly  and  with  force.  There  are  gulping  sounds.  The  difficulty  in 
swallowing  is  produced  by  liquids  as  well  as  by  solids.  The  patients  often 
complain  of  pain  which  is  constricting  and  burning  in  character.  Emacia- 
tion does  not  usually  occur.  The  bougie  is  not  always  arrested  at  the  same 
level  and  may  usually  be  passed  by  firm  pressure  beyond  the  point  of  re- 
sistance and  into  the  stomach. 

Pressure. — Narrowing  of  the  cesophagus  by  pressure  from  without 
may  be  caused  by  enlargement  of  the  thyroid  body,  as  in  goitre,  Graves's 
disease,  cystic  degeneration,  or  tumors  involving  that  organ  or  enlarged 
lymph-glands.  Within  the  thorax  a  mediastinal  tumor,  dislocation  back- 
ward of  the  sternal  end  of  the  clavicle,  prevertebral  abscesses  and  tumors, 
aneurism  of  the  aorta,  a  distended  diverticulum  or  massive  pericardial 
effusion  may  compress  the  cesophagus.  The  essential  symptom  is  dys- 
phagia. The  sound  may  usually  be  passed  with  persistent  gentle  pressure. 
If  there  is  reason  to  suspect  the  presence  of  an  aneurism  the  sound  must 
not  be  used.  The  cesophagus  adjusts  itself  to  external  pressure  to  a  re- 
markable degree  and  unless  it  is  extreme  the  symptoms  are  slight. 

Obstruction  from  plugging  may  result  in  infants  from  excessive  pro- 
liferation of  the  thrush  fungus;  at  any  period  of  life  from  any  foreign  body 
swallowed  by  accident  or  design.  Common  among  these  are  masses  of 
meat,  fragments  of  bone,  artificial  dentures,  jack-stones  and  other  small 
playthings.  Pedunculate  polypi  and  other  tumors  may  obstruct  the 
cesophagus  without  causing  stricture. 

Diverticula  or  circumscribed  lateral  dilatations  are  of  two  kinds, 
those  caused  by  internal  pressure — pulsion  diverticula — and  those  brought 
about  by  the  contraction  of  fibrous  tissue  outside  the  organ — traction 
diverticula. 


SYMPTOMS  AND  SIGNS:   (ESOPHAGUS.  515 

Pulsion  diverticula  first  show  themselves  by  discomfort  or  a  sense 
of  obstruction  after  swallowing  food,  usually  referred  to  the  sternal  region 
and  often  attended  by  cough.  After  a  time  liquids  only  can  be  taken  and 
are  sometimes  regurgitated  and  swallowed  again  and  again  before  reach- 
ing the  stomach.  Portions  of  food  may  be  regurgitated  several  hours 
after  having  been  swallowed.  Pressure  or  upward  stroking  of  the  left 
side  of  the  neck  may  aid  in  the  regurgitation  of  food.  A  tumor  is  not 
often  present.  Upon  auscultation  the  sound  produced  by  the  passage  of 
food  into  the  stomach  is  absent.  A  sound  may  be  introduced  into  the 
diverticulum,  the  blind  end  of  which  may  be  eight  inches — twenty  cm. — 
or  more  from  the  teeth;  it  may  pass  into  the  stomach  and  be  freely  mov- 
able in  that  organ;  or  one  sound  may  be  passed  into  the  diverticulum 
and  while  it  is  still  in  place  another  may  be  passed  beyond  it  into  the 
stomach.  The  symptoms  increase  in  severity  and  in  many  cases  there  is 
progressive  emaciation.    As  a  rule  the  progress  of  the  disease  is  tardy. 

Traction  diverticula  are  usually  situated  upon  the  anterior  or  lateral 
wall  and  near  the  bifurcation  of  the  trachea.  They  are  funnel-shaped 
and  vary  in  depth  from  one-half  to  three-quarters  of  an  inch  and  are 
usually  single  but  may  be  multiple.  They  commonly  give  rise  to  no  symp- 
toms. Particles  of  food  or  foreign  bodies  may,  however,  be  caught  in 
them  and  cause  ulceration  and  perforation,  with  bronchopneumonia, 
pulmonary  gangrene,  mediastinitis  or  pericarditis  and  pleurisy.  A  posi- 
tive diagnosis  cannot  be  made. 

Ulceration  may  cause  tenderness,  dysphagia;  perforation  the  secondary 
lesions  just  mentioned;  and  rupture,  which  usually  results  from  the  presence 
of  a  foreign  body,  may  cause  gangrenous  mediastinitis  and  pleurisy. 

(Esophageal  hemorrhage  may  result  from  ulcer,  cancer,  the  presence 
of  foreign  bodies,  the  rupture  of  an  aneurism  or  of  the  dilated  veins  of  the 
oesophageal  plexus  in  thrombosis >of  the  portal  vein  or  in  atrophic  cirrhosis 
of  the  liver. 

The  bleeding  may  be  occasional  or  constant  and  vary  in  quantity  from 
a  trifling  amount  to  a  copious  loss  which  is  quickly  fatal.  The  associated 
symptoms  may  render  the  diagnosis  easy,  but  in  the  case  of  varicose  veins 
the  differential  diagnosis  from  gastric  hemorrhage  is  often  difficult.  The 
presence  of  other  symptoms  of  portal  obstruction  and  the  fact  that  the 
blood  is  regurgitated  rather  than  vomited  are  to  be  considered,  but  the 
blood  may  be  discharged  into  the  stomach  and  subsequently  vomited. 

Inflammation  of  the  (Esophagus. — Oesophagitis  is  attended  by  local- 
ized or  diffuse  pain  upon  swallowing,  prostration,  and  in  the  severe  acute 
forms  by  chills  and  fever.  There  may  be  tenderness  upon  pressure  and 
upon  bending  the  spine;  for  this  reason  the  head  is  held  rigid.  Abscess 
formation  may  show  itself  by  a  circumscribed  swelling  upon  one  side  of 
the  neck  with  pressure  upon  the  larynx  and  hoarseness  and  dyspnoea.  In 
the  phlegmonous  form  pus  may  be  expectorated  and  in  the  chronic  cases 
a  glairy,  viscid  mucus. 

Tuberculous  and  syphilitic  ulcerations  occur  as  local  manifest  at  ions  in 
these  diseases,  and  their  presence  is  to  be  suspected  when  there  is  dyspha- 
gia, persistent  substernal  pain,  or  the  regurgitation  of  blood-stained  mucus 
in  connection  with  the  general  phenomena  of  these  diseases  respectively. 


516  MEDICAL  DIAGNOSIS. 

Paralysis.  —  The  oesophageal  muscles  are  sometimes  paralyzed  in 
central  or  peripheral  diseases  of  the  nervous  system.  Lesions  in  the  neigh- 
borhood of  the  origin  of  the  pneumogastric  nerves,  such  as  hemorrhage, 
softening,  tumor,  or  sclerosis,  are  among  the  central  causes;  pressure 
neuritis  of  the  pneumogastric  from  enlargement  of  the  lymphatic  glands, 
or  disease  of  the  vertebra?  and  toxic  neuritis  after  diphtheria  or  in  chronic 
alcoholism  or  lead  poisoning  are  among  the  peripheral  causes.  Difficulty 
of  swallowing,  without  pain,  is  a  characteristic  symptom.  It  develops 
gradually  or  abruptly,  according  to  the  cause.  The  food  produces  a  sense 
of  weight  or  pressure  and  a  large  bolus  is  more  readily  swallowed  than 
small  morsels.  Fluids  may  be  regurgitated.  Gurgling  sounds  attend  the 
act  of  swallowing,  but  the  normal  sound  at  the  cardia  is  not  heard.  The 
bougie  passes  freely. 


X. 

THE    DIGESTIVE   SYSTEM  (CONTINUED):   APPETITE;    THIRST 
ERUCTATIONS;     REGURGITATION;     NAUSEA;     VOMITING 
THE  VOMITUS;  DEFECATION;  CONSTIPATION;  DIARRHCEA 
TENESMUS;     PAINFUL     DEFECATION;     FECAL     INCONTI- 
NENCE;   CHARACTER  OF  THE  DISCHARGES. 

Appetite,  thirst,  the  frequency  of  defecation  and  the  consistency  and 
other  characters  of  the  stools  vary  within  wide  limits  in  health.  They  are 
to  a  considerable  extent  influenced  by  habit  and  the  mode  of  life  of  the 
individual.  Beyond  these  limits  they,  together  with  certain  associated 
symptoms,  acquire  clinical  significance  of  importance  in  disease  of  the 
digestive  organs  and  other  local  and  general  affections. 

APPETITE. 

Appetite  is  dependent  upon  the  state  of  the  gustatory  nerves,  the 
condition  of  the  stomach)  and  the  requirements  of  the  organism  as  a  whole. 

The  appetite  for  food  may  be  diminished,  lost — anorexia;  increased — 
polyphagia  or  bulimia;  perverted — pica  or  parorexia',  or  insatiable — acoria. 

Loss  of  appetite  varies  from  mere  indifference  to  food  to  complete 
anorexia.  It  is  symptomatic  of  the  most  varied  morbid  states,  the  enu- 
meration of  which  would  comprise  a  nosological  system. 

The  appetite  is  more  or  less  impaired  in: 

(a)  The  acute  infections.  The  absence  of  the  normal  desire  for  food 
is  due  chiefly  to  the  toxaemia,  and  in  part  to  the  subacute  gastritis  which 
is  usually  present. 

(b)  The  chronic  infections,  especially  in  the  active  stages  of  syphilis, 
tuberculosis,  and  malaria,  and  in  the  conditions  of  malnutrition  and  cachexia 
to  which  these  diseases  give   rise. 

(c)  Septic  conditions,  both  acute  and  chronic,  and  in  all  forms  of 
local  suppuration.     Loss  of  appetite  in  the  absence  of  gastric  disease  or 


SYMPTOMS  AXD  SIGNS:    APPETITE.  517 

other  adequate  obvious  cause,  especially  when  associated  with  persistent 
leucocytosis,  may  be  symptomatic  of  local  suppuration  in  some  part  of 
the  body. 

(d)  Pyrexia.  Fever  is  attended  by  loss  of  appetite  as  in  any  of  the 
foregoing  conditions,  and  this  symptom  is  commonly  present  in  the  early 
convalescence  from  febrile  diseases.  A  notable  exception  to  the  latter 
statement  occurs  in  enteric  fever,  in  which  hunger  is  usually  a  prominent 
and  urgent  symptom  after  the  defervescence. 

(e)  All  forms  of  ansemia,  chronic  wasting  diseases,  and  in  many 
functional  and  organic  diseases  of  the  nervous  system.  The  loss  of  appe- 
tite is  not  only  an  important  symptom  in  these  conditions  but  it  is  also 
an  etiological  factor.  A  vicious  circuit  is  established.  The  inability  to 
take  food  aggravates  the  condition  that  causes  it. 

A  remarkable  suppression  of  the  desire  for  food  is  manifest  in  certain 
cases  of  hysteria.  There  are  instances  in  which  the  suppression  of  appe- 
tite is  maintained  for  long  periods,  as  in  "fasting  girls."  Deception  is  to 
be  guarded  against.  To  hysteria  is  to  be  referred  the  condition  described 
by  Gull  as  anorexia  nervosa,  in  which  there  is  not  only  complete  loss  of 
appetite  but  also  absolute  inability  to  take  food,  with  the  gravest  symp- 
toms of  inanition,   sometimes  ending  in   death. 

(f)  Cachexias  and  terminal  states.  The  patient  is  not  only  unable 
to  take  food  save  in  minimum  quantities,  but  life  is  also  often  maintained 
without  it  for  considerable  periods — a  fact  due  to  the  extreme  limitation 
of  vital  activities. 

(g)  Toxic  conditions.  Complete  loss  of  appetite  attends  all  acute 
toxic  conditions,  and  there  is  great  impairment  in  chronic  intoxications, 
as  that  of  lead,  arsenic,  or  mercury.  The  anorexia  is  due  in  part  to  the 
general  malnutrition;  in  part  to  local  disorder  of  the  organs  of  digestion. 
In  chronic  alcoholism  appetite  is  irregular  and  enfeebled  and  at  the  close 
of  a  debauch  is  completely  lost.  Aversion  to  food  is  frequently  the  fore- 
runner of  an  attack  of  delirium  tremens. 

(h)  Psychic  states.  Depressing  emotional  conditions,  such  as  result 
from  worry,  anxiety,  suspense,  and  grief,  are  usually  attended  with  anorexia. 
The  impairment  of  appetite  under  these  circumstances  is  largely  depend- 
ent upon  the  temperament  of  the  individual. 

(i)  Functional  or  organic  disease  of  the  stomach.  Appetite  may 
persist  normally  or  in  some  abnormal  form  in  the  gastric  neuroses,  and 
is  maintained  in  some  cases  of  gastric  ulcer.  Patients  suffering  from 
disease  of  the  stomach  frequently  have  a  craving  for  food  which  is  im- 
mediately dispelled  upon  attempts  to  eat.  Loss  of  appetite  not  infre- 
quently results  from  a  monotonous  or  inadequate  dietary.  Under  these 
circumstances  the  appetite  frequently  returns  when  the  patient  is  per- 
mitted tn  take  ordinary  food.  There  is  a  French  proverb  to  the  effect 
that  appetite  comes  with  eating. 

Polyphagia  is  a  term  used  to  indicate  excessive  or  voracious  eating. 
It  may  be  occasional,  as  in  t lie  convalescence  from  enteric  fever  or  in  chil- 
dren suffering  from  whooping-cough,  the  frequent  vomiting  caused  by  the 
paroxysms  not  permitting  the  absorption  of  sufficient  food  to  meet  the 
needs  of  the  organism;   or  persistent,  as  ID  diabett 


518  MEDICAL  DIAGNOSIS. 

Bulimia  and  acoria  are  terms  used  to  designate  an  insatiable  appetite. 
This  is  symptomatic  of  certain  insanities  and  some  forms  of  idiocy  and 
occurs  in  paroxysms  in  certain  cases  of  hysteria,  neurasthenia,  epilepsy, 
and  exophthalmic  goitre.  In  polyphagia  the  patient  eats  large  quanti- 
ties of  food  and  is  for  the  time  being  satisfied.  In  bulimia  the  ordinary 
sense  of  satiety  after  eating  does  not  occur.  Acoria  is  the  loss  of  the 
sensation  of  satiety. 

Pica  or  parorexia  is  a  craving  for  unnatural  articles  of  food — a  de- 
praved appetite.  It  is  seen  in  some  cases  of  hysteria,  chlorosis,  and  in 
pregnancy.  These  terms  are  also  employed  to  designate  a  nervous  craving 
for  special  articles  of  diet  or  for  articles  that  are  not  fit  for  food. 

THIRST. 

Thirst  is  in  some  instances  an  individual  peculiarity.  There  are 
persons  who  rarely  experience  the  sensation  of  thirst  and  do  not  con- 
sume enough  fluid  to  fully  meet  the  requirements  of  the  body;  others 
who  without  impairment  of  health  manifest  an  habitually  abnormal 
desire  for  fluid. 

Impaired  Thirst. — The  sensation  of  thirst  is  diminished  in  soporous 
states,  even  when  the  buccal  and  salivary  secretions  are  diminished  and 
the  mouth  and  tongue  are  dry,  as  in  enteric  fever. 

Increased  thirst  is  symptomatic  of  many  morbid  states.  It  is  a  con- 
stant symptom  in  fevers  and  occurs  in  all  conditions  attended  with  abun- 
dant or  profuse  loss  of  fluids,  and  is  proportionate  to  the  dehydration  of 
the  tissues.  It  therefore  attends  profuse  sweating  both  physiological 
and  pathological,  abundant  diuresis  from  any  cause,  persistent  vomiting, 
abundant  watery  discharges  from  the  bowels,  and  sudden  copious  hemor- 
rhage. It  occurs  at  the  time  of  crisis  from  acute  diseases,  as  croupous 
pneumonia;  in  the  polyuria  of  hysteria  and  persistently  in  diabetes  insipi- 
dus and  mellitus;  in  the  copious  vomiting  of  acute  irritant  poisoning  and 
in  some  cases  of  uraemia;  after  the  action  of  eiaterium  and  other  drugs 
producing  large  watery  discharges  from  the  bowels;  in  cholera  nostras 
and  Asiatica  and  after  all  kinds  of  abundant  hemorrhages  both  pathologi- 
cal and  traumatic.  An  unusual  desire  for  water  is  observed  in  some  cases 
of  chronic  gastritis.  Persistent  excessive  thirst  is  very  often  the  first 
symptom  to  attract  attention  in  diabetes.  The  arrest  of  the  buccal  secre- 
tions in  xerostomia  or  dry  mouth  gives  rise  to  continued  and  distressing 
thirst.  Polydipsia  is  a  term  used  to  describe  the  habitual  taking  of  fluid 
in  excessive  amounts. 

ERUCTATIONS,  REGURGITATION,  NAUSEA,  AND 

VOMITING. 

The  oesophagus  enters  the  stomach  at  an  angle,  forming  a  valve- 
like fold  which  serves  to  prevent  the  return  of  the  contents  of  the 
stomach.  The  relation  of  the  central  tendon  of  the  diaphragm  to  the 
oesophagus  is  such  that  it  closes  the  oesophageal  opening  only  at  the 
time  of  inspiration. 


SYMPTOMS  AXD  SIGNS:    NAUSEA.  519 

Eructations  or  Belching. 

The  spasmodic  forcible  discharge  of  gas  or  air  from  the  mouth  is  a 
common  symptom.  It  may  come  from  the  oesophagus;  much  more  com- 
monly it  comes  from  the  stomach.  It  is  sometimes  odorless,  frequently 
offensive.  It  may  consist  of  air  swallowed  with  the  food  or  with  the  saliva, 
or  of  the  gaseous  products  of  the  chemical  decomposition  of  the  food  in 
the  stomach.  The  eructations  may  be  occasional  or  occur  in  paroxysms 
lasting  for  periods  of  some  hours.  Eructations  are  symptomatic  of 
acute  indigestion  such  as  results  from  over-eating,  various  forms  of 
gastritis  and  other  organic  affections  of  the  stomach,  or  they  may  be  of 
nervous  origin..  Large  quantities  of  odorless  gas  are  sometimes  forcibly 
expelled  at  intervals  during  a  period  of  several  hours  in  hysterical  and 
neurasthenic  individuals,  the  stomach  at  the  same  time  being  tensely 
distended. 

Regurgitation. 

The  liquid  portions  of  the  food,  and  in  some  instances  the  solids,  are  re- 
turned to  the  mouth  without  the  violence  characteristic  of  vomiting.  Regur- 
gitation from  the  oesophagus  occurs  as  a  symptom  of  stricture,  dilatation  or 
diverticulum,  the  food  being  returned  immediately  or  after  an  interval.  Re- 
gurgitation from  the  stomach  may  be  due  to  over-distention  with  food,  or 
drink  and  relaxation  of  the  cardiac  orifice.  The  regurgitation  of  considerable 
quantities  of  an  opalescent,  slightly  alkaline  fluid  is  spoken  of  as  water-brash. 

Merycism  or  rumination  is  the  regurgitation  of  solid  food  from  the 
stomach  to  the  mouth,  when  it  is  again  chewed  and  swallowed.  The  food 
is  returned  in  small  portions  without  nausea.  This  phenomenon  appears 
at  first  to  be  the  result  of  regurgitation,  later  a  habit. 

Pyrosis  or  heart-burn  is  a  burning  sensation  behind  the  sternum, 
extending  to  the  pharynx.  It  is  often  accompanied  by  eructation  and 
sometimes  by  the  regurgitation  of  an  acid  fluid.  It  is  due  to  the  ejection 
of  the  gastric  contents  into  the  oesophagus.  It  occurs  in  hyperchlorhydria 
but  may  appear  as  a  neurosis  when  the  gastric  secretion  is  normal. 

Nausea. 

Nausea  or  sickness  at  the  stomach  is  closely  associated  with  vomiting 
in  its  mechanism  and  clinical  significance.  It  belongs  to  the  group  of 
abnormal  sensations  referred  to  the  stomach,  and  occurs  in  functional 
and  organic  affections.  Those  causes  which  excite  vomiting  also  excite 
nausea,  though  the  latter  may  occur  in  the  absence  of  the  former.  The 
term  "nervous  nausea"  is  applied  to  this  symptom  when  it  arises  in  con- 
stitutional disorders  and  diseases  of  the  central  nervous  system.  It  is 
common  in  neurasthenia  and  hysteria  and  is  very  often  the  result  of  reflex 
irritation  in  distant  organs,  for  example,  the  uterus  and  ovaries.  Nausea 
is  very  common  in  the  early  stages  of  pregnancy,  and,  associated  with 
retching  and  vomiting,  constitutes  in  pregnancy  the  syndrome  known  as 
morning  sickness,  which  in  exceptional  cases  is  persistent  and  intractable 
and  may  even  cause  deal  h. 


520  MEDICAL  DIAGNOSIS. 

Vomiting. 

Vomiting  is  the  forcible  expulsion  of  the  contents  of  the  stomach 
through  the  mouth.  In  exceptional  cases  the  contents  of  the  intestines 
may  also  be  expelled  through  the  mouth — fecal  or  stercoraceous  vomiting. 

The  Muscular  Mechanism. — The  act  of  vomiting  is  a  complex  reflex 
movement  in  which  many  muscles  take  part.  There  is  usually  a  sensation 
of  nausea  and  a  reflex  flow  of  saliva  into  the  mouth,  accompanied  or  fol- 
lowed by  a  series  of  more  or  less  violent  retching  movements  which  consist 
of  deep  inspirations  with  closure  of  the  glottis.  As  a  result  of  these  move- 
ments the  stomach  is  compressed  by  the  diaphragm  and  the  negative  pres- 
sure in  the  thorax  and  especially  in  the  oesophagus  is  decidedly  increased. 
In  the  course  of  these  retching  movements  the  act  of  vomiting  is  brought 
about  by  a  sudden  convulsive  contraction  of  the  abdominal  muscles  which 
exerts  additional  pressure  upon  the  stomach.  With  this  the  cardiac  orifice 
of  the  stomach  is  dilated  and  the  stomach  contents  are  forced  through  the 
oesophagus,  the  glottis  being  closed  by  the  adductor  muscles  and  the  nasal 
chambers  shut  off  from  the  pharynx  by  the  contraction  of  the  posterior 
pillars  of  the  fauces  upon  the  palate  and  uvula.  In  the  vomiting  of  uncon- 
sciousness, as  in  anaesthesia,  the  laryngeal  muscles  may  relax  and  vomited 
matters  be  insufflated  into  the  trachea,  and  in  violent  vomiting  the  material 
may  in  part  be  forced  past  the  palate  and  uvula  and  ejected  through  the  nose. 

It  is  not  uncommon  for  the  contents  of  the  duodenum  to  be  forced 
by  the  violence  of  the  contraction  of  the  abdominal  muscles  through  the 
pylorus,  so  that  the  vomitus  consists  of  bile-stained  material  and  some- 
times of  pure  bile. 

The  muscles  concerned  in  vomiting  are  respiratory.  The  act  consists 
essentially  in  the  simultaneous  spasmodic  contraction  of  the  diaphragm, 
an  inspiratory  muscle,  and  the  abdominal  or  expiratory  muscles,  contrac- 
tion of  the  muscular  fibres  of  the  stomach  being  altogether  of  subsidiary 
importance. 

The  Nervous  Mechanism. — The  reflex  nature  of  vomiting  is  shown 
by  the  frequency  with  which  it  is  produced  by  the  stimulation  of  sensory 
nerves  and  by  injuries  to  various  parts  of  the  central  nervous  system. 
Disagreeable  emotions  and  derangements  of  the  equilibrium  of  the  body, 
irritation  of  the  mucous  membrane  of  various  parts  of  the  alimentary 
canal,  pathological  states  of  the  genito-urinary  tract,  and  lesions  or  injuries 
of  the  brain  may  all  cause  vomiting.  Vomiting  may  also  be  caused  by 
direct  action  upon  the  medullary  centres,  as  in  the  case  of  drugs — apomor- 
phine  and  various  narcotics — and  by  or  in  the  toxaemia  of  the  infections 
and  autointoxications,  as  uraemia  and  cholaemia. 

The  causes  are  many,  but  the  most  common  is  irritation  of  the  sensory 
fibres  of  the  gastric  mucous  membrane.  In  this  case  the  afferent  path  is 
by  way  of  the  sensory  fibres  of  the  vagus;  the  efferent  path  by  way  of  the 
motor  fibres  innervating  the  muscles  concerned  in  the  act  of  vomiting, 
namely,  the  vagi,  the  phrenics,  and  the  spinal  nerves  distributed  to  the 
abdominal  muscles.  It  is  now  generally  conceded  that  there  is  a  definite 
vomiting  centre  situated  in  the  medulla  in  close  proximity  to  the  respira- 
tory centre. 


SYMPTOMS  AND  SIGNS:   VOMITING. 


521 


The  readiness  with  which  children  vomit  is  due  in  part  to  the  greater 
reflex  excitability  of  the  nervous  system  in  early  life;  in  part  to  the  posi- 
tion of  the  stomach,  which  is  more  nearly  vertical  than  in  adults.  The 
undeveloped  state  of  the  fundus  and  the  defective  closure  of  the  cardia 
increase  the  liability  of  infants  to  vomiting,  which  often  occurs  without 
effort  as  a  mere  regurgitation  of  a  portion  of  the  food  upon  change  of 
posture  or  slight  pressure  upon  the  epigastrium. 


Brain 


Pharynx 


Liver  and  gall-bladder 


Stomach 

Kidney  and  ureter 
Intestines 

Uterus 

Bladder 

Vesical  nerves 


Vomiting  centre 
in  the  medulla 


Spinal  cord 


Vagus 

Pulmonary  branches 

Splanchnic  nerves 
Gall-duct 


Renal  nerves 
Mesenteric  nerves 
Vesical  nerves 
Uterine  nerves 


Fia.  200. — Diagram  of  afferent  nerves  which  may  excite  the  vomiting  centre. 
Modified  from  Brunton. 

1.  Vomiting  from  Direct  Irritation  of  the  Terminal  Fibres  of  the  Vagus 
in  the  Stomach. — Vomiting  from  this  cause  is  very  common.  It  may 
result  from  anatomical  lesions  of  the  stomach  itself  and  from  quantitative 
and  qualitative  abnormalities  of  the  contents  of  the  organ.  Vomiting 
is  a  common  phenomenon  in  various  forms  of  gastritis.  In  acute  gastric 
catarrh  there  is  vomiting  of  the  gastric  contents  followed  by  mucus 
often  stained  with  bile;  a  sense  of  relief  is  then  experienced.  In  chronic 
gastric  catarrh  vomiting  is  common;  it  occurs  at  various  intervals  after 
the  taking  of  food.  Frequently,  and  especially  in  the  gastric  catarrh  of 
alcoholic  subjects,  there  is  distressing  vomiting  of  tough  mucus  on  rising  — 
vomitus  matutinus  potatorum.     Vomiting  is  common  in  peptic  ulcer  of  the 


522  MEDICAL  DIAGNOSIS. 

stomach  and  is  frequently  provoked  by  the  intake  of  food,  which  also 
causes  pain.  The  pain  very  often  precedes  the  vomiting  and  is  relieved 
by  it.  The  vomiting  which  attends  carcinoma  ventriculi  is  a  common 
and  distressing  symptom.  It  is  not  often  present  until  the  disease  has 
made  considerable  progress.  It  may  occur  when  the  stomach  is  empty, 
but  usually  follows  the  ingestion  of  food,  after  varying  intervals.  When 
the  growth  involves  the  cardia  food  may  be  immediately  vomited;  when 
the  pylorus,  after  an  interval  of  several  hours.  Vomiting  may  be  absent 
in  carcinoma  of  the  fundus  or  lesser  curvature.  In  stenosis  of  the  pylorus 
from  carcinoma  or  other  cause  food  is  retained  in  the  stomach,  which  grad- 
ually undergoes  dilatation,  and  is  vomited  after  some  hours  or  a  day  or 
two — retention  vomiting.  The  vomiting  of  large  quantities  of  fluid  after 
considerable  intervals  of  time  is  characteristic  of  gastric  dilatation.  Vom- 
iting does  not  occur  in  gastrectasis  of  slight  degree  and  in  the  extreme 
cases,  by  reason  of  the  impaired  contractility  of  the  wall  of  the  stomach, 
may  wholly  cease — an  unfavorable  symptom.  Vomiting  is  a  common 
symptom  of  cholera  morbus  and  cholera  Asiatica  and  may  be  regarded 
as  the  direct  result  of  the  inflammation  of  the  gastric  mucous  membrane. 
It  usually  occurs  after  the  diarrhoea,  sometimes  coincidently  with  it, 
scarcely  ever  before  it.  Vomiting  in  cholera  is  usually  unattended  with 
effort,  is  frequently  repeated,  and  ceases  or  alternates  with  singultus  in 
the  algid  stage.  The  vomitus  is  liquid  and  sometimes  resembles  the  rice- 
water  discharges.  This  symptom  occurs  in  hyperacidity  and  hypersecre- 
tion and  may  be  so  persistent  in  cases  of  gastric  hyperesthesia  that  all 
food  is  promptly  ejected.  External  pressure  upon  the  stomach,  as  in  peri- 
carditis, ascites,  or  pericardial  effusion,  may  cause  vomiting. 

2.  Vomiting  from  Central  Irritation  of  the  Vagus. — To  this  cause  must 
be  referred  the  vomiting  which  is  so  common  in  diseases  of  the  brain 
and  its  membranes — anaemia,  hyperaemia,  concussion,  sea-sickness,  Meni- 
ere's disease,  tumor,  abscess,  and  various  forms  of  meningitis.  So-called 
cerebral  vomiting  is  characterized  by  the  absence  of  nausea,  its  sudden- 
ness, projectile  character,  and  the  fact  that  it  occurs  independently  of  the 
taking  of  food.  Vomiting  of  gastric  origin  is  mostly  followed  by  a  sense 
of  relief,  while  that  dependent  upon  cerebral  causes  usually  aggravates 
the  symptoms,  probably  because  of  the  mechanical  disturbance  produced 
by  the  act.  Vomiting  is  an  early  and  important  symptom  in  tuberculous 
meningitis  and  cerebrospinal  fever. 

3.  Reflex  Vomiting. — The  following  forms  are  to  be  considered: 

(a)  Vomiting  produced  by  irritation — tickling — of  the  base  of  the 
tongue  or  the  fauces.  Nausea,  gagging,  and  vomiting  are  frequently  caused 
by  the  unskilful  use  of  the  tongue-depressor  or  the  laryngoscopic  mirror. 
In  the  older  medicine  tickling  the  throat  with  a  feather  often  played  the 
part  of  an  emetic.  When  the  mucous  membrane  is  abnormally  sensitive, 
as  in  neurotic  individuals  or  as  the  result  of  acute  or  chronic  catarrh,  very 
slight  irritation  of  the  fauces  may  cause  vomiting.  The  vomiting  of  acute 
angina,  that  caused  by  efforts  to  dislodge  tough  masses  of  mucus,  that 
attendant  upon  hypertrophy  of  the  tonsils,  and  the  vomiting  which  accom- 
panies the  paroxysm  of  pertussis  must  be  referred  to  this  group.  The 
irritation  caused  by  partially  detached  diphtheritic  membrane  sometimes 


SYMPTOMS  AXD  SIGNS:   VOMITING.  523 

produces  efforts  at  vomiting  which  may  have  the  favorable  effect  of  wholly- 
detaching  the  mass. 

The  vomiting  of  consumption  is  sometimes  an  early  symptom;  it  is 
more  common  and  troublesome  in  the  later  stages.  It  is  frequently  caused 
by  severe  paroxysms  of  coughing.  The  vomiting  of  phthisis  may  be  cerebral, 
as  from  tuberculous  meningitis,  of  which  it  is  often  an  early  and  ominous 
symptom;  due  to  pressure  upon  the  vagi  by  caseous  glands;  the  mani- 
festation of  irritation  of  the  peripheral  distribution  of  the  vagi;  pulmonary, 
pharyngeal,  or  gastric  or  mechanical,  as  from  the  succussion  of  urgent  cough. 

(b)  The  vomiting  of  peritonitis,  which  is  frequently  severe  and  intract- 
able and  always  significant. 

(c)  That  caused  by  irritation  of  the  intestinal  mucous  membrane.  In 
some  instances  the  action  of  purgatives  is  preceded  by  vomiting.  This 
symptom  may  attend  intestinal  parasites,  colic,  enterocolitis,  appendicitis, 
strangulated  hernia,  intussusception,  torsion,  and  ileus.  In  any  form  of 
obstruction  of  the  bowel  retroperistalsis  may  occur  with  vomiting,  which 
gradually  becomes  stercoraceous. 

(d)  That  attendant  upon  visceral  diseases  of  various  kinds,  as  biliary 
and  renal  colic,  acute  nephritis,  pyelitis,  cystitis,  Addison's  disease,  and 
acute  yellow  atrophy  of  the  liver. 

(e)  That  which  is  symptomatic  of  disorders  of  the  female  sexual  organs. 
Vomiting  is  common  in  anomalies  of  menstruation,  uterine  displacements, 
and  pelvic  exudates  and  new  growths. 

Of  especial  importance  is  the  vomiting  of  pregnancy.  A  little  mucus 
is  thrown  up  with  great  nausea  and  effort  when  the  patient  rises  in  the 
morning.  Commonly  the  vomiting  does  not  recur  until  the  next  day; 
sometimes  it  is  persistent  and  distressing.  Usually  it  ceases  after  a  few 
months.     The  pernicious  form  has  been  spoken  of  above. 

(f)  So-called  nervous  vomiting.  The  most  typical  form  is  that  which 
occurs  in  hysteria.  It  depends  upon  the  hyperesthesia  and  abnormal 
motility  of  the  stomach  and  upon  quantitative  and  qualitative  changes 
in  the  gastric  secretions.  The  vomitus  is  often  of  large  amount  and  con- 
sists of  thin  fluid.  It  is  a  notable  fact  that  notwithstanding  persistent 
vomiting  hysterical  patients  lose  little  weight. 

The  persistent  vomiting  of  Leyden  is  a  form  of  nervous  vomiting 
characterized  by  recurrent  attacks  coming  on  without  obvious  cause  or  as 
the  result  of  slight  indigestion,  fatigue,  or  worry,  and  lasting  from  some 
hours  to  several  days.  The  vomiting  is  copious  and  continuous;  the 
abdomen  retracted  and  the  bowels  constipated.  There  is  epigastric  pain 
together  with  intense  headache  and  intolerance  of  light  and  sound.  The 
pulse  is  frequent  but  there  is  no  fever. 

The  gastric  crises  which  occur  in  tabes,  and  less  frequently  in  acute 
myelitis,  disseminated  sclerosis  and  paresis,  are  to  be  mentioned  in  this 
connection.  Together  with  distressing  pain  there  is  vomiting,  usually 
persistent  and  uncontrollable.  Food  is  at  first  ejected,  then  a  colorless 
stringy  fluid  and  in  some  cases  :t  blood-stained  mucus.  There  is  vertigo 
and  :i  sense  of  sinking  nt  the  pit  of  the  stomach.    The  attack  lasts  from 

some  hours  to  two  or  three  days.      In  the  intervals  there  may  be  no  signs 
of  gastric  dise 


524  MEDICAL  DIAGNOSIS. 

The  vomiting  of  migraine  belongs  to  the  category  of  nervous  vomiting. 

(g)  Reflex  vomiting  may  accompany  diseases  of  the  heart,  especially 
myocarditis,  fatty  heart  and  angina  pectoris.  Vomiting  due  to  cardiac 
disease  is  not  infrequently  associated  with  hiccough. 

4.  Direct  Irritation  of  the  Centre  for  Vomiting.  —  This  form  is  less 
frequent.    It  arises  under  the  following  conditions: 

(a)  The  action  of  certain  emetics  of  which  apomorphine  is  a  type. 

(b)  The  action  of  toxic  substances  in  the  blood,  as  for  example  those 
present  in  nephritis  both  acute  and  chronic.  Vomiting  is  an  early  and 
ominous  symptom  in  many  cases  of  uraemia  and  not  rarely  the  first  indica- 
tion of  contracted  kidneys.  Uraemic  vomiting  occurs  independently  of 
the  taking  of  food  and  is  often  severe  and  distressing. 

(c)  As  an  early  manifestation  of  the  toxaemia  of  the  acute  infections, 
especially  in  childhood.  Vomiting  may  attend  the  stage  of  onset  in  scarlet 
fever,  croupous  pneumonia,  diphtheria,  and  other  acute  febrile  diseases. 

The  Gross  Characteristics  of  the  Vomitus. 

The  general  appearance,  quantity,  odor,  and  reaction  of  the  ejected 
material  is  of  importance  in  diagnosis.  These  peculiarities  depend  largely 
upon  the  presence  or  absence  of  food  in  the  stomach,  its  character  and  the 
time  that  has  elapsed  since  its  ingestion.  When  vomiting  occurs  directly 
after  eating,  the  food  shows  little  or  no  change.  On  the  other  hand,  if  some 
hours  have  elapsed  there  may  be  no  trace  of  food.  In  retention  vomiting, 
however,  it  is  not  uncommon  to  find  particles  of  food  taken  at  a  previous 
meal  or  upon  a  preceding  day.  In  sucklings  the  appearance  of  the  vomited 
milk  is  of  importance.  The  presence  of  curds  indicates  the  presence  of 
the  milk-curdling  ferment;  an  uncurdled  milk  some  time  after  nursing 
shows  the  absence  of  normal  gastric  secretions  and  may  be  the  sign  of 
grave  changes  in  the  stomach. 

Aside  from  the  presence  of  food  the  following  peculiarities  are  of 
diagnostic  importance: 

Watery  Fluid  and  Mucus. — The  vomitus  may  consist  of  a  watery 
fluid  containing  little  or  no  mucus.  This  is  common  in  the  morning  in 
chronic  gastric  catarrh,  especially  that  of  alcoholic  subjects.  If  the  reac- 
tion is  alkaline,  the  fluid  usually  consists  of  saliva  that  has  been  swallowed 
during  the  night  and  the  vomitus  consists  largely  of  saliva  in  cases  in  which 
prolonged  nausea  has  preceded  the  act  of  vomiting.  If  the  reaction  be 
acid  the  vomitus  consists  either  of  gastric  fluid  in  excess — hypersecretion — 
or  of  food  and  mucus  that  have  undergone  acid  fermentation.  More  com- 
monly the  vomited  matter  contains  mucus  and  in  some  cases  of  acute  and 
chronic  gastric  catarrh  it  is  composed  of  masses  of  tenacious  mucus.  The 
vomiting  of  hyperacid  gastric  juice  occurs  in  peptic  ulcer  of  the  stomach 
and  in  neurotic  conditions,  as  migraine,  hysteria,  the  gastric  crises  of  tabes 
and  exophthalmic  goitre.  In  some  cases  of  cholera  the  contents  of  the 
intestines  are  forced  into  the  stomach  and  vomited,  presenting  the  usual 
characters  of  the  rice-water  discharges  and  containing  the  comma  bacilli 
of  Koch. 


SYMPTOMS  AXD  SIGNS:    VQMITIXG.  525 

Bilious  Vomiting. — Bile  is  very  commonly  present,  imparting  a  green 
or  yellow  color.  It  occurs  after  repeated  or  violent  vomiting  and  is  of  no 
great  diagnostic  importance.  The  early  vomiting  of  considerable  amounts 
of  bile  occurs  in  some  cases  of  peritonitis  and  intestinal  obstruction. 

Vomiting  of  Blood  —  Haematemesis  —  Gastrorrhagia.  —  This  symptom 
occurs  in  a  number  of  morbid  conditions  and  is  of  great  importance  in 
diagnosis.  The  differential  diagnosis  between  haematemesis  and  haemopty- 
sis has  already  been  considered.  The  vomited  blood  may  be  bright 
red  and  fluid — a  sign  that  it  has  remained  in  the  stomach  but  a  brief 
period;  or  it  may  consist  of  reddish  or  reddish-brown  clots  that  have 
formed  during  a  longer  period;  or  finally  it  may  present  the  appearance  of 
coffee  grounds,  indicating  that  it  has  been  subjected  to  the  action  of  the 
gastric  juice  for  a  sufficient  time  to  undergo  partial  digestion,  with  altera- 
tion of  the  haemoglobin  and  destruction  of  the  erythrocytes.  In  some 
instances  a  superficial  resemblance  to  recent  blood  may  be  due  to  the  pres- 
ence of  red  wine  or  various  reddish-colored  fruits  or  the  jellies  or  preserves 
made  from  them;  in  others  altered  blood — "coffee  grounds" — may  be 
suggested  by  the  presence  in  the  vomitus  of  coffee,  cocoa,  minute  frag- 
ments of  boiled  or  over-cooked  meat,  and  certain  drugs,  as  the  prepara- 
tions of  bismuth  and  iron.  As  a  rule  these  uncertainties  may  be  settled 
by  close  inspection  and  an  inquiry  into  the  facts,  but  there  are  rare  cases 
in  which  a  chemical,  microscopic,  or  spectroscopic  examination  may  be 
necessary  to  determine  the  question.  Bright  red  blood  is  usually  vomited 
in  considerable  amounts  and  in  association  with  small  clots,  while  the 
altered  blood  which  resembles  coffee  grounds  is  mixed  with  the  vomitus 
in  small  quantities. 

Not  all  blood  ejected  from  the  stomach  is  derived  from  the  vessels 
of  that  organ.  Blood  is  frequently  swallowed  and  then  vomited.  In 
haemoptysis  a  portion  of  the  blood  coughed  up  is  often  swallowed.  Blood 
readily  finds  its  way  from  the  nasal  chambers  or  pharynx  into  the  stomach, 
especially  when  the  patient  is  in  the  recumbent  posture.  The  blood  oozing 
from  the  bitten  tongue  in  the  epileptic  paroxysm  may  be  swallowed  during 
the  postepileptic  stupor  or  the  vomited  blood  may  be  derived  from  the 
vessels  of  the  oesophagus.  Blood  may  be  swallowed  by  malingerers,  who 
sometimes  suck  it  from  a  wound  made  for  the  purpose  in  the  mouth  or 
upon  the  hand  or  forearm.  In  very  rare  instances  infants  vomit  milk 
stained  with  blood  derived  from  a  fissured  or  ulcerated  nipple. 

Bleeding  from  the  stomach  occurs  under  various  conditions,  of  which 
the  following  are  important: 

1.  Circulatory  Derangements. — Portal  obstruction  and  the  re- 
sulting passive  hyperaemia  of  the  gastric  mucosa  lead  to  haematemesis. 
This  symptom  therefore  occurs  in  cirrhosis  of  the  liver,  in  malignant  and 
other  tumors  of  the  porta,  and  in  adhesive  pylephlebitis.  Copious  haematem- 
esis, occurring  in  hepatic  cirrhosis  and  terminating  fatally,  occasionally 
arises  from  rupture  of  the  veins  of  an  enlarged  oesophageal  plexus.  The 
visceral  congestions  resulting  from  cardiac  mural  and  valvular  disease 
tend  also  to  hemorrhage.  Haematemesis  is  occasionally  encountered  in 
massive  enlargement  of  the  spleen. 


526  MEDICAL  DIAGNOSIS. 

2.  KLemic  Disorders.  —  Haematemesis  is  frequently  symptomatic 
of  the  grave  anaemias.  It  occurs  in  pernicious  anaemia,  leukaemia,  haemo- 
philia, scurvy,  and  purpura  haemorrhagica,  in  profound  jaundice,  and  after 
extensive  burns.  It  has  been  observed  in  phosphorus  poisoning  and  in 
acute  yellow  atrophy  of  the  liver. 

3.  The  Infections. — Vomiting  of  blood  is  of  occasional  occurrence 
in  epidemic  influenza,  typhus,  relapsing  fever,  and  dengue.  It  is  a  promi- 
nent event  in  some  forms  of  pernicious  malarial  fever,  malignant  variola, 
and  yellow  fever.  In  the  last  the  vomiting  of  altered  blood — black  vomit — 
is  characteristic. 

4.  Traumatism. — Contusions  of  the  epigastric  region,  as  from  a  blow 
or  kick,  crushing,  and  other  injuries,  are  sometimes  followed  by  the  vomit- 
ing of  blood.  The  vomitus  is  often  blood-streaked  after  prolonged  or 
violent  vomiting.  Under  this  caption  must  be  placed  the  direct  injury  to 
the  gastric  mucosa  caused  by  the  corrosive  poisons,  caustic  alkalies,  the 
mineral  acids,  arsenic,  and  the  like. 

5.  Specific  Anatomical  Lesions  of  the  Stomach.  —  Cancer  is  a 
common  cause  of  gastric  hemorrhage.  The  blood  is  usually  dark  and 
altered  and  rarely  profuse,  slight  oozing,  either  continuous  or  frequently 
repeated,  being  the  rule.  Even  more  common  is  gastric  ulcer.  The  blood 
is  usually  abundant,  bright  red,  and  fluid.  Copious  haematemesis  is  sug- 
gestive of  ulcer.  Free  and  even  lethal  bleeding  may  occur  in  superficial 
erosions,  and  profuse  hemorrhage  may  come  from  the  erosions  of  the  gas- 
tric mucous  membrane  which  sometimes  occur  after  operations  upon  the 
abdomen  and  especially  in  cases  in  which  the  omentum  has  been  wounded. 
In  gastric  and  duodenal  ulcer,  especially  the  latter,  the  blood  may  not  be 
vomited  but  is  passed  in  the  stools.  Miliary  aneurism  is  a  rare  cause  of 
gastric  hemorrhage.  It  is  not  common  for  death  to  result  directly  from 
the  bleeding,  which  is  often  repeated  from  time  to  time.  Anaemia,  fre- 
quently of  high  grade,  results.  Syncope  with  or  without  general  convul- 
sions may  immediately  follow  profuse  hemorrhage.  Hemiplegia  and 
amaurosis,  which  may  be  followed  by  optic  atrophy,  are  rare  sequelae. 

6.  Certain  Nervous  Affections. — Haematemesis  is  an  occasional 
event  in  hysteria,,  and  cases  of  gastric  bleeding  have  occurred  in  apparently 
healthy  individuals  in  the'  absence  of  any  local  or  general  condition  to 
account  for  it,  and  without  a  second  appearance.  This  symptom  is 
comparatively  infrequent  in  epilepsy  and  in  general  paresis,  and  Schiff 
and  others  have  directed  attention  to  it  as  a  rare  phenomenon  in  local 
cerebral  disease.  In  the  newborn  it  may  occur  as  an  isolated  symptom 
or  with  hemorrhage  from  other  mucous  tracts. 

7.  Fatal  gastric  hemorrhage  may  result  from  the  rupture  of 
an  aneurism  of  the  aorta  or  its  branches  into  the  stomach.  Under  such 
circumstances  death  may  occur  from  blood  loss  without  vomiting,  the 
stomach  being  distended  with  blood. 

Fecal  or  Stercoraceous  Vomiting. — This  is  a  significant  symptom  in 
acute  obstruction  of  the  bowel.  The  anatomical  condition  may  be  strangu- 
lation, intussusception,  volvulus,  or  abnormal  contents.  The  last  of  these — 
fecal  masses,  biliary  calculi,  and  enteroliths — may  cause  acute  obstruction 
by  the  sudden  shifting  of  their  position.     Vomiting  comes  on  early  and  is 


SYMPTOMS  AND  SIGNS:    DEFECATION.  527 

persistent.  The  vomitus  consists  at  first  of  the  contents  of  the  stomach,  then 
of  bile  or  bile-stained  material,  and  finally  of  a  brownish  or  blackish  fluid  of 
a  distinctly  fecal  odor.  In  this  fluid  masses  of  fecal  matter  may  be  present. 
Retroperistalsis  not  rarely  occurs  in  peritonitis  and  in  some  cases  stercora- 
ceous  vomiting  is  the  result  of  a  gastro-intestinal  fistula.  Chronic  intesti- 
nal obstruction  is  not  usually  attended  by  this  form  of  vomiting  even 
when  of  high  grade.  In  the  terminal  paroxysms,  however,  it  may  occur. 
Purulent  vomiting  is  rare  and  not  usually  dependent  upon  primary 
disease  of  the  stomach;  it  may,  however,  occur  in  phlegmonous  gastritis. 
The  more  common  cause  is  perforative  ulceration  of  the  wall  of  the  stomach 
in  hepatic  abscess  or  empyema. 

Parasites  in  the  Vomit. — The  Ascaris  lumbricoides  occupies  the  upper 
part  of  the  small  intestine.  From  this  position  it  finds  its  way  readily 
into  the  stomach  and  is  often  ejected  with  the  vomit.  In  rare  cases  the 
segments  of  taenia  are  present  in  vomited  matter  and  the  hooklets  and 
fragments  of  echinococcus  cysts  have  been  observed;  so  also  trichinellae  and 
the  larvae  of  insects. 

The  quantity  of  the  vomitus  depends  upon  the  volume  of  the  stomach 
contents  and  the  intensity  of  the  act  of  vomiting.  Very  significant  is  the 
retention  vomiting  of  pyloric  obstruction  and  the  large  fluid  vomiting  in 
gastrectasis  from  other  causes. 

The  Odor. — The  vomit  is  commonly  sour-smelling  and  often  intensely 
acid.  It  is  ammoniacal  in  uraemia  and  fecal  in  acute  intestinal  obstruction 
and  in  some  cases  of  peritonitis.  The  odor  of  the  vomitus  in  poisoning  is 
sometimes  of  great  diagnostic  importance.  Striking  examples  are  carbolic 
acid,  the  garlicky  smell  in  phosphorus  poisoning,  that  of  bitter  almonds 
in  poisoning  by  hydrocyanic  acid  and  nitrobenzole,  the  vinegar-like  odor 
in  poisoning  by  acetic  acid,  and  the  smell  of  ammonia;  less  significant 
are  the  odors  of  alcohol  or  laudanum. 

The  reaction  is  commonly  acid.  Where  there  is  an  excess  of  saliva, 
bile,  or  blood  the  reaction  is  alkaline.  In  hypersecretion  the  reaction  is 
intensely  acid  and  patients  speak  of  their  teeth  being  set  on  edge  by  the 
Taste.     In  uraemia  the  reaction  may  be  alkaline. 

The  taste  of  the  vomitus  is,  according  to  the  patients,  commonly  sour 
and  when  bile  is  present,  bitter.     Blood  imparts  a  salty  or  sweetish  taste. 

DEFECATION. 

Significance  of  Abnormal  Defecation.  —  The  indigestible  parts  of 
the  food,  with  debris,  bacteria]  masses,  and  secretions  from  the  intestinal 
tract,  pass  slowly  through  the  large  intestine  and  reach  the  sigmoid  flexure, 
in  which  they  accumulate.  As  the  semisolid  or  solid  material  passes  into 
the  rectum  it  stimulates  the  sensory  nerves  of  that  part  of  the  intestine, 
giving  rise  t"  ;i  peculiar  sensation  and  desire  to  defecate.  This  material 
is  retained  in  the  reotum  by  the  two  sphincter  muscles,  the  internal  of 
which  is  a  band  of  the  circular  layer  of  involuntary  muscles  of  the  rectum. 
Upon  the  passage  of  fecal  matter  into  the  rectum  the  internal  sphincter 
passes  into  a  condition  of  tonic  contraction,  the  relaxation  of  which  marks 
the  beginning  of  the  act  of  defecation.    The  interna]  sphincter  is  composed 


528  MEDICAL  DIAGNOSIS. 

of  unstriped  muscular  fibre  and  receives  its  innervation  from  the  sympa- 
thetic system  and  from  the  sacrospinal  nerves.  The  external  sphincter 
ani  is  made  up  of  striated  muscular  fibres  and  is  to  a  large  extent  under  the 
control  of  the  will.  Upon  intense  rectal  stimulus  the  voluntary  control 
is  overcome  and  this  sphincter  is  also  relaxed.  The  act  of  defecation  is 
therefore  in  part  voluntary  and  in  part  involuntary.  The  voluntary  factor 
is  made  up  of  the  inhibition  of  the  external  sphincter  and  the  simultaneous 
action  of  the  abdominal  muscles,  the  diaphragm  being  contracted  and  the 
glottis  closed.  Pressure  is  thus  exerted  upon  the  abdominal  and  pelvic 
viscera,  with  the  result  that  the  contents  of  the  descending  colon  and  sig- 
moid flexure  are  forced  into  the  rectum.  This  pressure  is  augmented  by 
deep  inspiration  and  fixation  of  the  respiratory  muscles.  The  involun- 
tary factor  consists  in  the  contraction  of  the  muscles  of  the  rectum,  in 
particular  the  circular  layer,  and  the  relaxation  of  the  internal  sphincter, 
in  part  the  result  of  reflex  stimulation  from  the  lumbar  cord  and  in 
part  from  automatic  peristaltic  movements.  The  action  of  defecation  is 
essentially,  however,  an  involuntary  reflex,  as  is  well  seen  in  infants  and 
in  soporose  states. 

Under  normal  conditions  the  bowels  move  once  a  day,  the  act  being, 
like  sleep  and  the  taking  of  food,  of  diurnal  rhythmical  recurrence.  There 
are  healthy  individuals,  however,  in  whom  the  rhythm  is  not  diurnal,  but 
at  intervals  of  two  or  three  days  or  exceptionally  longer,  and  in  whom  efforts 
to  bring  about  the  diurnal  movement  by  means  of  purgatives  are  followed 
by  manifest  derangements  of  health.  The  normal  periodical  movement  of 
the  bowels  is  maintained  by  the  observation  of  a  fixed  hour  for  this  function, 
and  various  derangements,  especially  constipation,  result  from  the  neglect 
of  this  rule. 

It  is  important  for  the  physician  to  inform  himself  as  to  the  periodicity, 
frequency,  and  character  of  the  bowel  movements  and  in  certain  cases  to 
inspect  the  stools.  Departures  from  the  normal  in  respect  of  this  function 
relate  to  constipation,  diarrhoea,  tenesmus,  painful  defecation,  fecal  incon- 
tinence, and  the  character  of  the  discharges. 

CONSTIPATION. 

Constipation — costiveness — infrequent  or  difficult  evacuation  of  faeces; 
retention  of  faeces.  This  condition  is  of  great  and  varied  diagnostic  impor- 
tance. Its  cause  may  be  constitutional  or  intestinal.  Very  often  several 
causes  are  associated. 

The  more  important  constitutional  or  general  causes  of  constipation  are: 

1.  Personal  peculiarity:  Sluggishness  of  the  bowels  is  frequently  an 
hereditary  and  family  tendency.  It  is  far  more  common  in  persons  of  dark 
than  in  those  of  fair  complexion  and  is  especially  associated  with  the  traits 
that  constitute  the  bilious  temperament. 

2.  Unhygienic  habits,  as  want  of  proper  exercise,  the  failure  to  observe 
regularity  in  the  hour  of  defecation  or  to  devote  to  the  act  sufficient  time, 
irregularity  or  undue  haste  in  meals  and  the  eating  of  unwholesome  food  or 
of  excessive  quantities  of  food.  From  this  point  of  view  constipation  is 
primarily  not  a  condition  of  the  body  but  a  condition  of  the  mind.    On  the 


SYMPTOMS  AND  SIGNS:   CONSTIPATION.  529 

other  hand  too  little  food  or  a  diet  consisting  largely  of  proteid  substances 
or  which  contains  a  minimum  of  undigested  residuum  tends  to  constipa- 
tion. It  is  obvious  that  a  sufficient  bulk  of  residual  material  is  required  to 
form  the  fecal  mass  and  excite  peristalsis.  The  insufficient  ingestion  of 
fluid  tends  also  to  cause  constipation. 

3.  Dehydration  of  the  tissues  by  profuse  and  frequently  repeated 
sweating,  diuresis  from  the  action  of  drugs,  the  polyuria  of  diabetes  insip- 
idus and  mellitus,  or  repeated  hemorrhages  is  attended  by  constipation. 

4.  The  febrile  infections,  except  those  in  which  diarrhoea  is  an  especial 
symptom,  are  characterized  by  a  tendency  to  constipation.  Even  in 
these  affections  constipation  very  often  gives  way  in  the  later  course  of  the 
attack  to  diarrhoea,  and  the  latter  may  assume  the  guise  of  a  critical  dis- 
charge, as  sometimes  occurs  in  croupous  pneumonia. 

5.  The  habitual  use  of  purgative  drugs  is  a  fruitful  cause  of  constipation. 

6.  Constipation  is  a  very  common  condition  in  the  anaemias,  especially 
in  chlorosis,  and  is  often  a  troublesome  symptom  in  neurasthenia  and 
hysteria. 

7.  General  asthenia  and  cachectic  states  are  very  often  attended  by 
constipation;  so  also  conditions  in  which  the  abdominal  muscles  are  over- 
distended  and  their  contraction  hampered,  as  obesity,  ascites,  large  ab- 
dominal tumors,  and  pregnancy. 

Among  local  causes  of  constipation  the  following  are  to  be  considered: 

1.  Alterations  in  the  quantity  and  quality  of  the  intestinal  juices  and 
a  deficiency  of  bile  or  pancreatic  secretion.  Under  these  circumstances 
constipation  may  be  an  important  symptom  of  fever,  chronic  diseases  of  the 
gastro-intestinal  tract,,  and  diseases  of  the  liver,  biliary  passages,  and  the 
pancreas.  It  is  to  be  borne  in  mind  that  the  normal  presence  of  bile  in  the 
intestine  constitutes  a  powerful  stimulus  to  peristalsis. 

2.  The  motor  mechanism  of  the  intestine  may  be  at  fault.  The  defect 
may  be  nervous,  as  in  organic  disease  of  the  nervous  system — myelitis, 
meningitis,  and  tetanus,  or  functional,  as  in  hysteria  and  neurasthenia. 
Or  the  defective  intestinal  innervation  may  be  the  manifestation  of  a  general 
asthenia.  The  arrest  of  peristalsis  and  tympanites  in  severe  enteritis, 
some  cases  of  appendicitis  and  in  peritonitis  and  acute  pancreatitis  are 
primarily  due  to  derangements  of  the  nerve-supply  to  the  bowel,  second^ 
arily  to  paresis  of  its  muscular  wall.  Chronic  intestinal  catarrh  and  portal 
congestion  from  hepatic  or  cardiac  disease  are  often  attended  by  constipation 
due  to  impaired  nutrition  of  the  muscular  coat  of  the  bowel.  Atony  of  the 
colon  and  especially  of  the  muscular  wall  of  the  sigmoid  flexure  is  an  im- 
portant local  cause  of  constipation.  Dilatation  of  the  colon  is  attended 
with  constipation.  Large  collections  of  scybala  may  accumulate  in  the 
sigmoid  flexure  and  be  felt  upon  palpation  of  the  abdomen.  Constipation 
due  to  this  cause  is  encountered  in  neurasthenia  and  hysterical  persons 
and  is  common  in  the  insane.  It  occurs  also  in  bed-ridden  and  elderly 
individuals. 

3.  Local  disease  of  the  rectum  or  anus  or  of  adjacent  organs  is  a  com- 
mon cause  of  constipation.  When  such  conditions,  as  is  usually  the  case. 
render  t  he  act  of  defecation  painful,  t  lie  patient  is  apt  to  postpone  it  unduly 
and  there  is  very  often  reflex  spasm  of  the  sphincters  which  renders  it  for 

34 


530  MEDICAL  DIAGNOSIS. 

the  time  impossible.  Under  these  circumstances  fecal  material  accumu- 
lates in  the  rectum  and  sigmoid  flexure  of  the  colon  and  greatly  adds  to  the 
discomfort  of  the  patient.  Such  local  disorders  are  inflamed  hemorrhoids, 
anal  fissure,  irritable  ulcer,  prostatic  inflammation  or  abscess,  and  a  tender 
retroverted  uterus  or  prolapsed  ovary. 

4.  Constipation  is  observed  in  malignant  disease  of  the  oesophagus, 
pylorus  and  bowel  and  in  other  chronic  conditions  in  which  a  minimum  of 
food  is  ingested  or  that  which  is  taken  cannot  pass  onward  or  is  persistently 
vomited. 

5.  This  symptom  may  be  due  to  a  contracted  condition  of  the  bowel — 
so-called  spasmodic  constipation.  The  narrowing  of  the  bowel  may  be  the 
result  of  ulcerative  colitis  or  dysentery;  a  manifestation  of  hysteria  or  of 
the  atrophic  processes  of  advanced  life.  The  bowel  may  be  in  a  condition 
of  permanent  contraction  or  spasm  at  one  part  and  dilated  elsewhere. 
The  stools  are  small  and  sausage-shaped  or  they  may  be  liquid  with  hard 
scybalous  masses  varying  in  size  from  a  marble  to  a  walnut.  Spasmodic 
constipation  occurs  in  the  pelvic  disorders  of  women  and  in  chronic  lead 
poisoning. 

6.  Strangulated  hernia  is  attended  with  acute  constipation.  Laxatives 
are  without  effect.  There  are  vomiting  and  abdominal  distention.  Pain  is 
usually  present.  Similar  symptoms  attend  volvulus  and  other  forms  of 
intra-abdominal  strangulation.  In  intussusception,  the  sausage-like  tumor, 
tenesmus,  bloody  mucus,  and  a  relaxed  anus  are  significant.  Acute  reten- 
tion of  faeces  with  the  signs  of  obstruction  demands  very  careful  and  sys- 
tematic examination  of  the  abdomen,  a  digital  exploration  of  the  rectum, 
and  examination  of  the  hernial  rings. 

Chronic  intestinal  obstruction  may  be  due  to  foreign  bodies,  very  large 
gall-stones,  tumors  within  the  gut  or  exerting  pressure  upon  its  wall,  masses 
of  scybala,  and  strictures  of  every  kind.  The  constipation  is  gradually 
developed;  occasionally  interrupted  by  watery  diarrhoea  and  sometimes 
by  attacks  with  the  symptoms  of  acute  obstruction.  Three  facts  are  of 
great  importance:  First,  that  fluid  fecal  matter  may  work  its  way  past 
the  obstruction  from  time  to  time;  second,  that  the  dilated  and  con- 
gested bowel  below  the  obstruction  may  discharge  a  thin  fecal-stained 
mucus;  and,  finally,  that  both  these  conditions  are  occasionally  mistaken 
for  diarrhoea. 

7.  Constipation  in  infants.  Constipation  in  the  new-born  may  be 
due  to  imperforate  anus  or  a  congenital  stricture.  In  some  cases  it  results 
from  dilatation  of  the  colon,  which  may  attain  enormous  dimensions,  or  it 
may  be  due  to  simple  atony  of  the  large  bowel. 

Constipation  in  sucklings  and  especially  in  bottle-fed  infants  is  often 
due  to  deficiency  of  the  intestinal  secretions,  the  faces  being  dry  and  hard. 
This  condition  has  been  attributed  to  insufficient  water  and  a  deficiency  of 
fat  in  the  food.  In  older  children  attention  to  the  hour  of  defecation  and 
regular  habits  are  as  important  as  in  later  life.  Constipation  often  results 
from  enterocolitis,  from  impairment  of  the  contractility  of  the  muscular 
wall  and  derangement  of  the  normal  secretions.  Acute  constipation  is 
frequently  symptomatic  of  mechanical  obstruction  by  foreign  bodies,  hard- 
ened and  impacted  fasces,  twists,  and  intussusception. 


SYMPTOMS  AND  SIGNS:    DIARRHCEA.  531 

Associated  Symptoms. — Sensations  of  pressure  and  distention  in  the 
abdomen,  uneasiness  and  pain,  especially  in  the  course  of  the  transverse 
colon,  loss  of  appetite,  a  furred  tongue,  a  disagreeable  taste,  and  uneasy 
precordial  sensations  are  common.  Patients  very  often  attribute  these 
phenomena  to  derangements  of  the  liver  or  stpmach.  An  effectual  purge 
is  of  diagnostic  importance.  The  results  very  often  show  that  these  symp- 
toms are  due  to  constipation. 

Of  especial  importance  are  the  morbid  phenomena  in  the  distribution 
of  the  hemorrhoidal  veins  that  result  from  constipation.  Pain  before  and 
after  defecation,  protrusion  of  the  dilated  blood-vessels,  bleeding  and  the 
discharge  of  stringy  mucus  are  common.  Paroxysmal  neuralgic  pain 
referred  to  the  coccyx  or  the  suprapubic  region  or  to  the  inner  aspect  of  the 
thigh  are  less  frequent.  Gastric  catarrh  with  manifold  symptoms  and 
occasional  implication  of  the  duodenum  and  bile  passages  also  occurs.  In 
some  instances  catarrhal  jaundice  results  and  in  chronic  constipation  a 
slight  icteric  discoloration  of  the  conjunctiva  is  often  seen. 

Constitutional  derangements  are  not  less  common.  They  consist 
of  headache,  vertigo,  depression  of  spirits,  disinclination  for  work,  and 
debility.  Actual  neurasthenia  with  the  most  varied  and  depressing  symp- 
toms may  result  from  obstinate  and  prolonged  constipation.  It  is  on  the 
other  hand  important  to  bear  in  mind  that  nervous  disease  is  a  frequent 
cause  of  constipation  and  that  the  most  troublesome  constipation  may 
occur,  for  example,  in  hysteria.  Under  such  circumstances  a  vicious  circuit 
is  established,  the  constipation  aggravating  and  intensifying  the  symptoms 
of  the  disease  of  which  it  is  itself  a  symptom. 

The  duration  of  constipation  is  largely  dependent  upon  its  cause. 
Simple  forms  resulting  from  neglect  of  hygienic  laws  may  last  three  or  four 
days;  more  troublesome  cases  may  resist  usual  treatment  for  weeks. 
Stubborn  constipation  with  severe  symptoms  suggests  mechanical  obstruc- 
tion of  the  bowel.  The  passage  of  flatus  is  a  favorable  sign.  In  tran- 
sient constipation  the  indican  in  the  urine  is  not  increased;  in  chronic 
obstruction  it  is  apt  to  be  increased. 

DIARRHCEA. 

Abnormal  frequency  and  diminished  consistence  of  the  stools.  This 
symptom  is  of  the  most  varied  significance.  It  results  from  increased 
peristalsis,  particularly  when  the  large  intestine  is  affected,  from  diminished 
absorption  of  the  contents  of  the  bowel,  from  an  excess  of  fluid  in  the  bowel 
either  in  consequence  of  hypersecretion  of  the  substances  entering  into  the 
format  ion  of  the  8UCCU8  entericus  or  of  transudation  of  serum,  and  in  rare 
instances  from  direct  abnormal  communication  between  the  stomach  or 
small  intestine  and  the  colon. 

Diarrhoea  may  therefore  be  symptomatic  of  deranged  innervation  of 
the  bowel,  mechanical  or  chemical  irritation  by  its  contents,  the  action  of 
toxic  substances,  cit  her  in  t  he  bowel  or  in  the  blood-current,  as  in  poisoning, 
autointoxication  or  the  infections,  defective  nutrition  or  circulatory  de- 
rangements of  the  wall  of  the  bowel,  or  local  disease,  as  ulceration  or  new 
growths  in  the  bowel  itself  or  adjacent  organs. 


532  MEDICAL  DIAGNOSIS. 

Diarrhoea  may  be  primary  or  secondary  or  it  may  be  acute  or  chronic. 
The  number  of  stools  varies  from  3  or  4  to  30  or  more  in  the  course  of 
twenty-four  hours,  their  consistency  from  semisolid  to  watery,  and  their 
color,  odor,  and  other  physical  characters  vary  within  equally  wide  ranges 
(see  pp.  534,  535). 

The  recognition  of  the  following  forms  of  diarrhoea  is  essential: 

1.  Nervous  diarrhoea.  This  s3rmptom  may  denote  mere  increase  of 
peristalsis  in  the  absence  of  any  lesion  of  the  intestine,  in  hysteria, 
neurasthenia,  the  intestinal  crises  of  tabes,  exophthalmic  goitre,  Addison's 
disease,  movable  kidney,  in  the  first  dentition,  and  in  emotional  disturb- 
ances in  healthy  individuals  of  neurotic  temperament.  The  character- 
istic manifestations  of  the  underlying  nervous  disorder  are  of  diagnostic 
importance.  The  stools  are  of  gruel-like  consistence  and  contain  noth- 
ing of  pathological  importance.  The  attack  begins  abruptly  and  is  of 
short  duration. 

2.  Irritation  of  the  intestine  secondary  to  constitutional  conditions. 
Diarrhoea  may  occur  in  ursemia,  hyperpyrexia,  extensive  burns,  sudden 
chilling  of  the  surface,  certain  infectious  conditions,  as  malaria  and  septi- 
caemia, and  as  the  result  of  the  subcutaneous  injection  of  such  purgatives 
as  podophyllin  or  magnesium  sulphate.  The  urine  should  be  examined 
in  every  case. 

3.  Increased  intestinal  fluid.  The  stools  are  abnormally  frequent 
and  watery  after  the  administration  of  the  hydragogue  cathartics  and  in 
cholera  nostras  and  Asiatica. 

4.  Irritation  of  the  intestine  by  various  ingesta,  or  pathological 
bowel  contents.  Abnormal  peristalsis  and  looseness  of  the  bowels  is  caused 
by  indigestion,  intestinal  parasites,  local  fecal  accumulations,  poisoning 
by  the  salts  of  mercury,  antimony,  arsenic,  copper  and  so  forth,  the  pur- 
gative drugs,  organic  acids  derived  from  the  food  or  from  its  decomposition 
in  the  stomach  or  intestines,  mushroom  poisoning,  unaccustomed  or  im- 
proper articles  of  diet,  bulky  or  indigestible  food,  large  quantities  of  cold 
food  or  drink,  or  the  administration  of  enemata.  In  all  cases  the  anamnesis 
and  physical  examination  are  of  diagnostic  importance. 

5.  Abnormal  irritability  of  the  bowel.  Diarrhoea  may  be  the  mani- 
festation of  an  idiosyncrasy,  and  is  symptomatic  of  catarrhal  inflammation 
and  of  ulcerative  processes  of  all  kinds,  from  superficial  erosions  from 
mechanical  irritation  to  the  specific  ulcerations  of  enteric  fever,  dysentery, 
or  tuberculosis. 

6.  Impaired  absorption.  Diarrhoea  is  not  rarely  due  to  extensive 
ulceration  or  atrophy  of  the  mucosa,  amyloid  disease,  and  portal  congestion. 
The  diarrhoea  of  tabes  mesenterica  is  largely  due  to  failure  in  fat  absorption. 

7.  Mucous  colitis  —  membranous  enterocolitis.  This  syndrome  is 
characterized  b}^  paroxysmal  diarrhoea  accompanied  by  severe  hypogastric 
or  left  iliac  pain  and  the  discharge  of  masses  of  mucus  or  membranous  casts 
of  the  bowel.  The  attack  occurs  at  varying  intervals,  and  the  disease  is 
observed  in  neurotic  persons,  usually  women. 

8.  Under  very  unusual  circumstances  a  fistulous  communication 
between  the  stomach  or  upper  part  of  the  intestine  and  the  colon — 
usually  its  transverse  part — may  be  the  cause  of  diarrhoea  with  stools 


SYMPTOMS  AND  SIGNS:   TENESMUS.  533 

containing  undigested  food  and  conversely  of  the  eructation  of  intestinal 
gas  or  the  vomiting  of  fecal  material. 

9.  Lienteric  diarrhoea.  Normal  stools  are  usually  more  or  less  homo- 
geneous. They  frequently,  however,  contain  such  indigestible  articles  as 
seeds,  husks,  the  capsules  of  berries,  fruit  pits,  and  the  like.  The  diarrhoea 
caused  by  excessive  quantities  of  food  or  the  ingestion  of  food  that  cannot 
be  digested,  or  which  attends  forms  of  enteritis  that  interfere  with  normal 
digestion  is  characterized  by  the  presence  in  the  stools  of  undigested  or 
only  partially  digested  particles  of  food  and  is  known  as  lienteric.  Frag- 
ments of  food  may  be  recognized  in  the  stools  shortly  after  it  has  been 
eaten.  This  form  of  diarrhoea  may  be  acute,  as  after  errors  in  diet  or  acute 
enteritis,  or  chronic,  as  in  chronic  intestinal  catarrh. 

Associated  Symptoms. — Diarrhoea  is  often  unattended  by  any  symp- 
tom other  than  the  frequent  recurrence  of  the  peculiar  sensation  which 
invites  to  the  closet.  Usually  there  is  uneasiness  in  the  abdomen,  which 
may  be  associated  with  local  or  general  pain,  often  colicky,  and  tenderness. 
Severe  diarrhoea  is  attended  with  thirst,  appetite  is  impaired,  and  there  is 
debility  proportionate  to  the  urgency  of  the  intestinal  symptoms.  Local 
or  general  tympanitic  distention  of  the  bowel  also  occurs.  Vomiting  is 
common,  especially  in  the  diarrhoeas  of  infancy.  The  loss  of  fluid  not  only 
causes  thirst,  but  may  give  rise  to  faintness,  collapse,  cramps  of  the  muscles, 
subnormal  temperature,  diminution  of  urine  even  to  suppression  and  albu- 
minuria. The  acidity  of  the  urine  is  increased  and  it  gives  the  reaction 
for  indican. 

TENESMUS. 

Rectal  tenesmus — painful,  ineffectual,  and  usually  long-continued 
straining  at  stool.  This  symptom  occurs  alone,  but  it  is  very  often  asso- 
ciated with  vesical  tenesmus,  partly  because  of  the  anatomical  relationship 
of  the  organs,  partly  because  of  the  common  action  of  some  of  the  causes. 
It  consists  of  spasm  of  the  musculature  concerned  in  defecation  and  micturi- 
tion. The  violent  spasmodic  contractions  are  repeated  at  short  intervals 
and  are  attended  with  such  distress  that  in  extreme  cases  children  fall  into 
general  convulsions  and  adults  faint.  The  discharge  consists  of  small 
amounts  of  stringy,  sometimes  bloody,  mucus  from  the  anus  or  a  few  drops 
of  urine  as  the  case  may  be.  Rectal  tenesmus  occurs  in  the  course  of  irri- 
tating lesions  of  the  rectum  and  anus,  whether  these  be  primary  or  second- 
ary. It  is  a  symptom  of  intussusception,  dysentery,  polypus,  adenoma  and 
malignant  tumors  of  the  rectum  and  sigmoid  flexure,  proctitis  and  peri- 
proctitis, hydatid  cysts  of  the  pelvis,  mechanical  injuries  to  the  rectum  by 
foreign  bodies,  or  in  exceptional  cases  in  highly  neurotic  persons  it  may 
follow  digital  or  instrumental  examination.  Tenesmus  is  not  a  common 
symptom  of  hemorrhoids  or  fissure  of  the  anus.  It  may  be  caused  by  im- 
pacted faeces,  masses  of  round  worms,  the  presence  of  foreign  bodies,  and,  in 
connection  with  vesical  tenesmus,  by  stone  in  the  bladder.  It  is  also  a 
distressing  symptom  in  acute  inflammation  and  abscess  of  the  prostate 
gland.  Tenesmus  is  easily  recognized.  Its  cause  may  be  obscure.  When 
it  is  violent  or  persistent  a  digital  or  proctoscopic  examination  should  be 
made  under  local  or  general  anaesthesia 


534  MEDICAL  DIAGNOSIS. 

PAINFUL  DEFECATION. 

The  pain  may  be  such  as  to  cause  fecal  impaction  from  voluntary 
postponement  of  the  act.  The  passage  of  a  large  hard  fecal  mass  is  attended 
with  pain  under  normal  conditions.  In  proctitis,  inflamed  hemorrhoids, 
fissure  of  the  anus,  prolapsus,  irritable  ulcer,  and  malignant  disease  of  the 
rectum  pain  upon  defecation  is  a  conspicuous  symptom.  It  is  usually  pres- 
ent in  inflammation  of  the  prostate  and  is  sometimes  symptomatic  of  acute 
inflammatory  affections  of  the  pelvic  organs  in  women. 

FECAL  INCONTINENCE. 

This  symptom  may  be  due  to  local  causes,  as  laceration  of  the  peri- 
neum involving  the  anal  sphincters,  surgical  over-stretching,  and  malig- 
nant or  syphilitic  disease  of  the  rectum;  more  commonly  it  is  due  to 
general  conditions  which  profoundly  affect  the  nervous  system,  as  coma 
from  any  cause,  myelitis  and  other  diseases  of  the  spinal  cord,  grave  chorea, 
convulsive  diseases,  as  epilepsy,  tetanus,  and  strychnine  poisoning,  and 
certain  severe  infections,  as  enteric  fever,  dysentery,  cholera  Asiatica  and 
nostras  and  cholera  infantum.  Involuntary  discharges  very  often  precede 
dissolution.  The  unclean  habits  of  some  forms  of  insanity  cannot  be 
placed  in  this  group  of  symptoms. 

THE  GROSS  PHYSICAL  CHARACTERS  OF  THE 

STOOLS. 

The  fecal  discharges  of  the  healthy  adult  are  of  brownish  color,  cylin- 
drical form,  soft  solid  or  semisolid  consistency,  150  to  200  grammes  in 
daily  quantity,  usually  neutral  or  faintly  alkaline  in  reaction  when  passed, 
and  emit  the  offensive  characteristic  odor. 

Abnormal  variations  in  these  respects  constitute  diagnostic  criteria 
of  some  importance.  The  macroscopic  examination  is  too  often  neglected. 
Laboratory  investigation  is  sometimes  necessary  (see  p.  229). 

1.  The  color,  which  is  due  to  the  presence  of  altered  bile  pigment, 
principally  hydrobilirubinj  may  be  modified  by  certain  articles  of  diet  or  by 
drugs.  It  may  be  rendered  black  by  blueberries  or  by  iron,  manganese, 
or  bismuth;  yellow  by  rhubarb,  colchicum,  senna,  or  santonin;  green 
by  spinach  or  calomel  or  by  certain  chromatogenous  bacteria.  In 
sucklings  and  others  who  subsist  upon  an  exclusive  diet  of  milk  the  faeces 
are  golden  yellow  or  whitish;  in  those  who  live  largely  on  meat  they  are 
brownish-black  in  color,  and  this  is  also  the  case  with  fecal  matter  long 
retained  in  the  bowel  as  in  obstruction.  In  jaundice  due  to  obstruction 
they  are  grayish  or  putty-colored.  When  they  are  increased  and 
thinned  by  intestinal  hypersecretion  or  transudation  their  color  is  usually 
light  brown  or  yellowish;  when  very  watery,  as  in  cholera,  they  are  of  a 
dirty-gray  color— rice-water  discharges.  The  presence  of  blood  colors  the 
stools  red  or  black:  red  when  the  blood  comes  in  considerable  quantity 
under  active  peristalsis  from  the  ileum  as  in  enteric  fever,  or  when  it  comes 
from  the  lower  bowel  as  in  dysentery,  or  from  the  rectum  as  in  piles;  black 


SYMPTOMS  AND  SIGNS:    STOOLS.  535 

when  it  is  derived  from  the  upper  regions  of  the  gastro-intestinal  tract  as  in 
peptic  ulcer,  or  when  it  is  thoroughly  mixed  with  the  stool. 

2.  The  form  is  lost  in  diarrhoea,  the  discharge  being  gruel-like  or  watery 
in  consistence.  The  normal  cylindrical  or  sausage-shaped  stool  may  be 
modified  in  various  conditions  of  the  lower  bowel.  In  prolapsus  ani  or 
stricture  of  the  rectum,  more  rarely  in  intussusception,  the  diameter  may 
be  much  narrowed — pipe-stem  stools;  in  stricture  or  cancer  of  the  rectum 
or  the  pressure  of  an  enlarged  prostate  gland  or  abscess  or  in  large  pelvic 
tumors  impinging  upon  the  rectum  the  stools  may  be  flattened  or  ribbon- 
shaped;  in  constipation  from  any  cause,  but  especially  that  which  results 
from  atony  and  distention  of  the  colon,  they  often  assume  the  form  of 
irregular,  round,  hard  masses  like  the  dung  of  sheep — scybala. 

3.  The  consistence  is  increased  in  constipation.  The  fluid  is  resorbed 
and  the  mass  tends  to  become  hard  and  dry.  The  consistence  is  diminished 
in  diarrhoea.  Serous  stools  are  observed  in  cholera  Asiatica,  cholera  nostras 
and  cholera  infantum;  in  poisoning  by  antimony,  arsenic,  and  mushrooms. 
Small,  dribbling,  serous  stools  occur  in  some  cases  of  intestinal  obstruction 
from  cancer  and  other  causes.  Serous  stools  contain  little  or  no  fecal 
matter. 

4.  The  quantity  varies  greatly.  It  is  diminished  when  the  diet  is 
concentrated  or  consists  principally  of  meat;  increased  when  the  diet  is 
largely  made  up  of  starchy  and  vegetable  foods.  The  amount  voided  at 
one  effort  depends  of  course  upon  the  frequency  of  the  act  and  may  attain 
in  cases  of  constipation  as  much  as  1000  grammes.  The  quantity  in 
diarrhoea  is  increased  by  the  hypersecretion  of  the  intestinal  glands  and 
the  transudation  of  serum  from  the  blood-vessels.  In  starvation  the  total 
quantity  may  not  exceed  90  grammes  a  day. 

5.  The  reaction  and  odor.  The  reaction  is  faintly  acid  in  nursing 
infants  and  alkaline  in  some  forms  of  intestinal  fermentation.  The  acidity 
is  due  to  carbohydrate  fermentation  or  the  presence  of  fatty  acids.  The 
reaction  is  of  no  great  diagnostic  value.  Depending  upon  the  amount  of 
proteid  decomposition  and  the  putrefactive  bacteria  present,  the  odor  of 
thf  stools  is  more  or  less  offensive.  Diets  that  allow  much  proteid  resi- 
due to  reach  the  large  bowel  usually  give  foul-smelling  movements*  A 
milk  diet  in  health  gives  an  almost  odorless  stool.  Indol  and  skatol, 
derivatives  of  proteid  decomposition,  are  mainly  responsible  for  the 
characteristic  fecal  odor. 

The  odor  in  healthy  infants  is  sour  and  unlike  the  fecal  odor  of  the 
stools  of  adults.  The  so-called  "  albuminous  decomposition"  in  the  faeces 
of  infants  and  the  resulting  putrid  odor  are  due  to  the  decomposition  of 
the  undigested  proteid  of  the  milk  in  the  Large  intestine.  In  cholera 
infantum  it  is  sometimes  faintly  musty,  sometimes  suggestive  of  the 
washings  of  meat.  In  the  absence  of  bile  the  stools  have  a  peculiarly 
offensive  odor. 

The  presence  of  milk  curds  in  the  stools  of  infants  indicates  an  error 
in  the  quantity  or  quality  of  the  food  and  is  one  of  the  earlier  symptoms  of 
enterocolitis;  the  presence  of  curds  in  the  stools  of  adults  who  are  taking 
a  milk  diet,  as  in  enteric  fi-\cv.  constitutes  an  indication  for  the  use  of 
alkalies  in  connection  with  the  milk  or  a  reduction  in  its  quantity. 


536  MEDICAL  DIAGNOSIS. 

Abnormal  Substances  in  the  Stools. — In  lienteric  diarrhoea  the  stools 
contain  undigested  particles  of  food.  Other  abnormal  substances  are  by 
no  means  uncommon  and  may  be  of  great  diagnostic  importance.  Among 
these  are  mucus,  blood,  pus,  fat  in  excess,  gall-stones,  intestinal  sand,  con- 
cretions, intestinal  parasites,  sloughs,  and  foreign  bodies  that  have  been 
swallowed. 

Mucus. — Minute  particles  of  mucus  may  be  observed  upon  the  surface 
of  the  formed  stools  in  health.  Large  quantities  covering  the  stools  or 
expelled  with  them  in  masses  indicate  a  deranged  secretion  of  the  mucous 
glands  of  the  colon  or  rectum.  Masses  of  mucus  that  may  be  shaken  out 
in  water  into  sheets  or  tubular  casts  of  the  intestine  are  diagnostic  of 
membranous  colitis.  Mucus  intimately  admixed  with  the  fecal  matter  may 
come  from  the  small  bowel.  Mucus  in  the  stools  is  symptomatic  of  mechan- 
ical or  pathological  irritation  of  the  bowel  and  is  seen  in  such  conditions  as 
impacted  faeces,  foreign  bodies,  intestinal  parasitism,  new  growths,  intus- 
susception, and  all  forms  of  dysentery,  enterocolitis,  and  proctitis. 

Blood. — A  distinction  is  made  between  "hemorrhage  from  the  bowel" 
— the  discharge  of  red  blood  unmixed  with  fecal  matter — and  "melsena" — 
blood  intimately  mixed  with  the  faeces  and  occurring  in  the  form  of  "  tarry" 
or  pitch-like  masses,  usually  of  semisolid  consistence  and  glistening  appear- 
ance. The  difference  consists  chiefly  in  the  time  the  blood  remains  in  the 
intestine  and  therefore  in  general  terms  indicates  the  portion  of  the  gut 
into  which  it  has  been  discharged.  If,  as  in  the  case  of  peptic  ulcer  of  the 
stomach  or  duodenum,  the  hemorrhage  has  been  high  up  in  the  intestinal 
tract,  the  blood  remains  a  considerable  time  in  the  bowel,  and  is  subjected 
to  mechanical  conditions  by  which  it  is  incorporated  with  the  fecal  contents, 
undergoing  at  the  same  time  a  sort  of  digestion  by  which  its  physical 
characters  are  much  changed.  If,  on  the  other  hand,  the  blood  is  poured 
out  lower  down  in  the  bowel  and  under  the  influence  of  an  active  peri- 
stalsis is  speedily  evacuated,  it  maintains  the  characteristic  appearance  of 
fresh  blood,  often  bright  red  and  sometimes  commingled  with  recently 
formed  clots.  The  appearance  of  the  evacuations  therefore  is  of  diagnostic 
importance  in  this  respect.  On  the  other  hand,  a  copious  hemorrhage  from 
the  ileum,  as  in  enteric  fever  with  active  peristaltic  movement,  usually 
shows  itself  in  the  discharge  from  the  bowel  of  bright  red  blood,  while  a 
slow  oozing  from  the  colon  with  tardy  onward  propulsion  in  the  bowel 
may  appear  in  the  stools  as  "coffee-grounds"  or  even  as  "tarry"  material. 

Blood  is  frequently  present  in  the  stools  in  quantities  so  minute  that 
its  presence  can  onty  be  detected  by  chemical  examination — occult  blood 
(Part  II,  p.  232). 

The  more  important  causes  of  blood  in  the  stools  are  portal  congestion, 
ulceration  of  the  intestinal  mucosa,  neoplasmata  and  in  particular  malig- 
nant disease  of  the  gut,  intestinal  parasites,  embolism  of  the  mesenteric 
arteries,  intussusception,  and  traumatism. 

1.  Portal  Congestion. — This  occurs  in  cirrhosis  of  the  liver,  portal 
thrombosis,  and  dilatation  of  the  hemorrhoidal  veins — piles.  The  diagnosis 
of  hemorrhoids  rests  upon  the  habitual  or  occasional  discharge  of  bright 
red  blood  with  the  stools,  the  appearance  and  habits  of  the  patient,  and  the 
signs  obtained  upon  inspection  or  a  digital  examination. 


SYMPTOMS  AND  SIGXS:    STOOLS.  537 

2.  Ulcerative  Processes  in  the  Bo wel.— Intestinal  hemorrhage  occur- 
ring in  the  course  of  an  attack  of  enteric  fever  is  of  positive  diagnostic  im- 
portance. It  means  the  erosion  of  an  arterial  twig  in  an  ulcer.  If  the 
hemorrhage  is  profuse  it  may  at  once  lead  to  collapse  with  the  associated 
symptoms  of  internal  hemorrhage;  if  slight,  the  stools  may  be  tarry  or 
contain  slight  amounts  of  red  blood  without  symptoms.  In  either  case  the 
appearance  of  blood  in  the  stools  is  of  prognostic  importance,  since  it 
denotes  deep  ulceration  which  may  be  followed  in  a  day  or  two  by  a  more 
abundant  blood  loss  or  by  perforation.  Other  ulcerative  processes  that 
lead  to  the  appearance  of  blood  in  the  stools  are  dysentery,  syphilis,  and 
tuberculosis.  Under  these  conditions  the  blood  appears  in  the  form  of 
streaks  or  stripes  upon  the  stools  or  admixed  with  mucus  or  pus.  Dysen- 
teric stools  may  present  the  appearance  of  meat  washings  or  of  masses  of 
blood  commingled  with  liquid  fecal  matter.  The  mere  presence  of  blood 
in  the  stools  does  not  under  ordinary  circumstances  justify  a  diagnosis. 
The  anamnesis  and  a  systematic  investigation  of  the  present  condition  of 
the  patient  are  necessary. 

3.  Malignant  Disease  of  the  Bowel. — Blood  in  the  stools  is  in  many 
cases  the  first  symptom  to  attract  the  attention  of  the  patient  to  carcinoma. 
The  stools  are  not,  however,  characteristic,  and  a  systematic  examination, 
which  may  reveal  the  presence  of  an  abdominal  tumor,  is  necessary.  General 
failure  of  health,  secondary  anaemia,  signs  of  intestinal  obstruction,  and 
cachectic  phenomena  are  confirmative. 

4.  Intestinal  Parasites. — The  Ankylostomum  duodenale  is  a  common 
cause  of  persistent  melaena  among  workers  in  the  soil  and  miners.  Grie- 
singer  first  drew  attention  to  this  parasite  as  the  cause  of  Egyptian  chlorosis. 
The  worms  infest  the  upper  portion  of  the  small  intestine  and  are  very 
abundant  in  the  jejunum.  The  diagnosis  rests  upon  the  prevalence  of  the 
condition  among  workmen  in  tunnels,  brick-yards,  excavations.,  and  the 
like,  and  the  presence  of  the  ova  in  the  stools. 

5.  Embolism,  of  the  Mesenteric  Arteries — Infarction  of  the  Bowel. — 
In  consequence  of  valvular  lesions  of  the  heart,  but  with  no  great  frequency, 
embolism  of  this  distribution  may  occur.  It  is  probable  that  the  occlu- 
sion of  small  vessels  produces  no  symptoms  of  importance  and  that  the  cir- 
culation may  be  reestablished.  If  the  superior  mesenteric  artery  is  occluded, 
or  a  large  branch,  the  symptoms  are  sudden  collapse,  violent  colicky  pains, 
signs  of  peritonitis,  and  thin,  blood-tinged  stools  or  hemorrhage  from 
the  bowel. 

6.  Intussusception. — This  affection  occurs  in  infancy  and  childhood. 
Bloody  stools  are  of  diagnostic  importance  since  they  occur  in  at  least 
sixty  per  cent,  of  the  cases  either  spontaneously  or  after  the  administration 
of  an  enema.  The  blood  is  commonly  mixed  with  mucus.  Associated 
symptoms  are  tenesmus  and  a  sausage-shaped  tumor  in  the  line  of  the  colon. 
Vomiting  and  tympany  are  less  common. 

7.  Traumatism. — Injuries  of  the  bowel  as  a  cause  of  bloody  stools 
commonly  involve  the  rectum,  and  when  they  do  not  penetrate  the  peri- 
toneum may  be  readily  overlooked.  The  abundant  venous  supply  favors 
free  bleeding,  and,  since  the  blood  is  often  retained  in  consequence  of 
spasm  of  the  sphincters,  the  signs  for  a  time  may  be  simply  those  of  inter- 


538  MEDICAL  DIAGNOSIS. 

nal  hemorrhage  and  collapse.  The  anamnesis  is  of  importance  and  a  digi- 
tal examination  reveals  the  actual  condition.  The  presence  of  foreign 
bodies  may  be  thus  discovered  in  children,  idiots,  and  insane  persons. 

8.  Constitutional  Conditions. — Intestinal  hemorrhage  is  occasionally 
symptomatic  of  leukaemia,  haemophilia,  purpura  haemorrhagica,  and  scurvjr. 
This  symptom  is,  however,  so  closely  associated  with  the  general  phenomena 
of  those  diseases  that  it  is  of  secondary  importance  in  their  diagnosis. 

9.  Miscellaneous  Causes  of  Intestinal  Hemorrhage. — Bloody  stools  are 
of  infrequent  occurrence  in  consequence  of  the  rupture  of  an  aneurism  of 
the  abdominal  aorta  into  the  bowel,  jaundice,  acute  yellow  atrophy  of 
the  liver,  phosphorus  poisoning,  yellow  fever,  pernicious  malarial  fever, 
and  very  rarely  septicaemia. 

Concealed  Hemorrhage.  —  Concealed  intestinal  hemorrhage  may 
occur  in  the  foregoing  conditions.  If  small  it  may  give  rise  to  no  symp- 
toms, although  prolonged  and  unsuspected  bleeding  may  be  the  cause  of 
profound  secondary  anaemia  with  its  usual  symptoms;  if  large  the  hemor- 
rhage, while  not  for  a  time  appearing  at  the  anus,  occasions  the  symptoms 
of  internal  hemorrhage, — namely,  collapse,  restlessness,  air-hunger,  pallor, 
a  pinched  face,  cold  extremities,  a  rapid,  weak,  even  imperceptible  pulse, 
urgent  thirst,  and  a  tendency  to  syncope. 

Pus. — In  small  quantities  pus  may  be  present  in  the  stools  in  dysen- 
tery, enteritis,  colitis,  proctitis,  and  in  ulceration  of  the  colon  or  rectum 
due  to  malignant  growths  or  syphilis.  Small  amounts  of  pus  may  be  present 
in  the  stools  in  profuse  leucorrhoea  or  urethritis;  but  under  these  cir- 
cumstances its  appearance  is  without  diagnostic  importance,  since  the 
associated  symptoms  will  fully  explain  it.  In  large  quantities  and  usually 
in  single  discharges,  or  in  large  quantities  at  irregular  intervals,  pus  may 
be  present  in  the  stools  in  consequence  of  the  rupture  of  an  abscess,  or 
the  establishment  of  a  fistulous  communication  between  a  purulent  collec- 
tion and  the  bowel.  Such  abscesses  are  usually  periproctic,  pelvic,  or 
perinephric;  sometimes  appendicular;  and,  less  commonly,  in  the  gall- 
bladder, hepatic  or  infradiaphragmatic. 

Fatty  Stools. — The  appearance  of  the  discharges  is  greasy  and  glisten- 
ing. An  excess  of  neutral  fat  is  present  in  obstructive  jaundice  and  in  vari- 
ous forms  of  pancreatic  disease.  Fatty  diarrhoea,  with  icterus  and  sugar  in 
the  urine,  has  been  observed  in  acute  suppurative  pancreatitis.  Over- 
feeding and  indigestion  in  infants  may  be  the  cause  of  fatty  stools,  and 
Biedert  has  described  a  fat  diarrhoea  in  which  the  percentage  of  fat  is 
enormously  increased.  The  condition  is  primary  in  which  the  ingestion  of 
fat  is  excessive  and  which  may  be  corrected  by  modification  of  the  food, 
and  secondary  which  is  due  to  catarrhal  inflammation  of  the  intestine  or 
disease  of  the  pancreas. 

GalUstones — Biliary  Calculi.  —  Gall-stones  have  been  found  to  be 
present  in  Europeans  in  from  5  to  10  per  cent.  In  the  East  gall-stones  are 
said  to  be  extremely  rare.  Gall-stones  vary  in  size  from  a  concretion  barely 
perceptible  to  the  naked  eye  to  the  size  of  a  walnut  or  larger.  The}r  are 
spherical,  oval,  or  angular,  the  surface  being  smooth,  mammillated,  or 
faceted.  When  large  they  are  commonly  single;  when  small  they  may 
number  hundreds.    In  a  case  of  mine  the  small  stones  numbered  by  actual 


SYMPTOMS  AXD  SIGNS:    STOOLS.  539 

count  300.  When  extremely  small  they  are  described  as  biliary  or 
intestinal  sand.  Their  color  varies  from  a  whitish-gray  to  dark  yellow 
or  brown,  sometimes  black.  Their  consistence  is  usually  firm,  but  they 
are  often  friable,  being  crushed  by  pressure  between  the  thumb  and 
forefinger,  with  crystalline  fracture.  In  some  cases,  however,  they  are 
extremely   hard. 

Intestinal  Sand. — Small  brown  or  green  calculi,  spherical  or  irregular 
in  shape  and  of  rough  surface,  and  varying  in  size  from  grains  of  sand  to 
small  shot,  are  sometimes  present  in  the  stools  in  considerable  quantity. 
This  material  may  or  may  not  be  preceded  by  attacks  of  colic.  These 
calculi  are  of  variable  composition.  They  consist  in  some  instances  of 
inorganic  salts,  as  calcium  carbonates  and  phosphates,  magnesia  and  iron, 
together  with  organic  matter,  bacteria  and  urobilin.  Cholesterin  is  not 
present.  A  nucleus  may  sometimes  be  demonstrated.  It  is  formed  of  a 
grain  of  quartz  sand  or  a  minute  particle  of  the  case  of  a  fruit  seed.  In 
other  very  rare  cases  calcium  sulphate  has  been  the  chief  constituent. 
This  form  of  intestinal  sand  occurs  in  intestinal  neuroses  of  the  secre- 
tory type. 

Pancreatic  Calculi. — Kinnicutt  has  recently  studied  the  subject  of  the 
discharge  of  pancreatic  calculi  during  life.  The  decisive  evidence  of  pan- 
creatic lithiasis  consists  in  the  presence  of  the  characteristic  concretions  in 
the  stools.  They  are  composed  chiefly  of  calcium  carbonate.  They  are 
extremely  rare — a  fact  due  in  part  to  the  small  size  of  the  calculi  and 
their  friability,  so  that  they  may  be  voided  in  fragments  or  particles  not 
easily  recognized. 

Intestinal  Concretions  —  Enteroliths.  —  Concretions  of  various  kinds 
occur  in  the  stools.  The}'  are  comparatively  rare.  The  following  forms  are 
encountered : 

1.  Hard  round  fecal  masses — scybala.  They  occur  in  chronic  consti- 
pation, especially  in  elderly  people,  and  in  cases  in  which  after  abdom- 
inal operation  partial  obstruction  of  the  bowel  occurs  as  the  result  of 
adhesions. 

2.  Enteroliths.  Earthy  concretions  are  sometimes  observed  in  the 
stools.  They  are  largely  composed  of  magnesium  phosphate,  the  alkaline 
carbonates,  and  organic  matter.  They  are  hard,  dense,  and  made  up  of  con- 
centric layers  about  a  chalky  nucleus  that  very  often  surrounds  a  foreign 
body.  They  are  usually  oval  and  are  very  rarely,  when  several  are  present, 
faceted,  and  occur  in  early  and  middle  life. 

'A.  Concretions  composed  of  vegetable  fibres  or  of  hairs  that  have 
been  swallowed  are  light,  porous,  usually  of  irregular  shape,  and  frequently 
show  upon  section  open  spaces  or  cavities  in  their  substance.  They  are 
sometimes  found  in  the  caecum  and  may  attain  the  size  of  an  orange.  They 
arc  sometimes  made  up  of  the  insufficiently  ground  husks  of  oats  or  the 
capsules  of  small  fruits.  They  occur  more  commonly  in  early  life  and  in 
females. 

4.  Certain  drugs  and  similar  substances,  as  chalk,  magnesia,  bismuth, 
ami  shellac,  when  taken  in  undue  quantities,  form  intestinal  concretions, 
which  appear  in  the  stools  ami  reveal  their  true  nature  only  upon  chemical 
examination. 


540  MEDICAL  DIAGNOSIS. 

Intestinal  concretions  when  of  small  size  occasion  no  characteristic 
symptoms.  When  of  larger  size  they  may  be  arrested  at  a  point  of  stenosis 
of  the  bowel,  or  upon  the  occurrence  of  contraction  and  cedematous  swell- 
ing, and  they  may  then  give  rise  to  the  symptoms  of  intestinal  obstruction. 
Large  concretions  are  usually  arrested  in  the  caecum,  in  the  colon,  or  in  the 
ampullae  of  the  rectum,  less  frequently  above  the  ileocaecal  valve.  Obstruc- 
tion in  the  upper  part  of  the  small  intestine  may  be  caused  by  concretions 
formed  in  the  stomach  or  by  gall-stones. 

Intestinal  Parasites.  —  The  Ascaris  lumbricoides  —  round  worm —  and 
its  ova  are  frequently  found  in  the  stools  of  children  and  young  adults. 
Oxyuris  vermicularis  —  thread-worm,  pin-worm,  —  a  very  common  para- 
site, infests  the  rectum  and  colon;  intestinal  cestodes  —  tape-worms  — 
of  which  the  common  forms  are  the  Tamia  saginata  or  medio canellata, 
the  Tamia  solium,  and  the  Bothriocephalus  latus,  show  themselves  in  the 
stools  in  the  form  of  segments  or  proglottides,  and  their  ova  are  usually 
present  in  great  numbers  (seep.  254,  Vol.  II). 

Sloughs. — The  invaginated  portion  of  the  bowel  in  intussusception 
may  slough  off  en  masse  and  be  discharged  from  the  bowel.  Polypi  of  the 
intestine  or  rectum  may  also  become  detached  by  sloughing  and  be  dis- 
charged with  the  faeces.  Masses  of  necrotic  tissue  may  become  separated 
from  malignant  or  other  ulcerating  growths  in  the  intestine  and  be  dis- 
charged with  the  faeces.  They  are  to  be  distinguished  from  fragments  of 
undigested  meat.  The  intestinal  sloughs  in  enteric  fever  may  sometimes 
be  recognized  in  the  stools  and  are  often  mistaken  for  milk  curds. 

Foreign  Bodies. — The  most  diverse  articles  may  be  found  in  the  stools, 
having  been  swallowed  by  accident  or  design.  Small  articles  of  all  kinds 
may  be  swallowed  by  children,  idiots,  and  dements;  bird-seed  and  the  like 
by  hysterical  persons;  coins,  rings,  and  gems  by  professional  thieves; 
nails,  glass,  fragments  of  china,  etc.,  by  fakirs,  and  such  articles  as  artificial 
teeth  or  even  a  clinical  thermometer  by  unconscious  persons,  and  all  of 
these  things  have  been  voided  with  the  stools. 


XL 

THE    SKIN;    PHYSIOLOGICAL  AND    PATHOLOGICAL   CHANGES 

AND  THEIR  SIGNIFICANCE;    (EDEMA;    SUPERFICIAL 

VASCULAR  CHANGES;  NAILS;  HAIR. 

THE  SKIN. 

Changes  in  the  skin  not  only  occur  as  manifestations  of  cutaneous  affec- 
tions but  they  also  constitute  important  diagnostic  signs  of  diseases  of  the 
internal  organs.  The  methods  of  examination  are  inspection  and  palpation. 
The  clothing  is  to  be  so  arranged  as  to  facilitate  the  necessary  investigation. 

The  condition  of  the  skin  varies  within  physiological  limits  at  different 
periods  of  life  and  in  the  sexes.  In  infancy  and  childhood  the  skin  is  dis- 
tensible, elastic   full,  of  fine  texture,  and  faint  rosy  color.    The  capillary 


SYMPTOMS  AND  SIGNS:    SKIN.  541 

circulation  is  active,  pressure  causes  local  pallor  which  quickly  disappears. 
In  middle  life  the  skin  is  finer,  softer,  and  shows  more  physiological  tur- 
gescence  in  women  than  in  men.  With  advancing  age  the  skin  loses  its 
elasticity.  Partly  for  this  reason,  partly  on  account  of  the  diminished 
amount  of  subcutaneous  fat;  and  partly  because  of  the  larger  development 
of  connective  tissue,  wrinkles  develop.  The  skin  in  elderly  persons  is  paler 
and  more  abundantly  pigmented  than  in  the  young.  The  skin  of  very  fat 
persons  frequently  has  a  disagreeable  unctuous  feel;  it  may  be  firm  and 
tense  or  loose  and  flabby.  The  skin  is  sometimes  flabby  and  relaxed  in 
fat  babies  who  are  not  properly  fed.  In  the  cachexias  of  infancy,  such 
as  that  of  congenital  syphilis  or  marasmus,  the  skin  is  muddy,  loose, 
inelastic,  and  sometimes  wrinkled  like  that  of  old  men. 

Color. — The  normal  tint  of  the  skin,  the  so-called  flesh  color,  depends 
upon  the  blood  showing  through  the  upper  layers  of  the  integument  and 
the  epidermis.  The  changes  in  color  are  quantitative  and  qualitative, 
physiological  and  pathological.  Quantitative  changes  consist  in  varying 
degrees  of  color,  from  blushing  to  blanching.  They  are  best  observed  upon 
the  face.  On  the  other  hand  qualitative  changes  in  the  color  of  the  skin 
are  studied  best  upon  other  parts  of  the  body  where  the  flesh  color  is  paler 
and  less  variable.  The  mucous  membrane  of  the  conjunctiva,  lips,  and 
mouth  must  always  be  examined. 

Variations  in  the  flesh  color  depend  upon  the  amount  of  blood  in  the 
cutaneous  vessels,  the  amount  of  the  blood-coloring  matter,  that  is,  the 
percentage  of  haemoglobin,  and  the  thickness  of  the  tissues  covering  the 
vessels.  It  is  obvious  that  since  any  of  these  factors  may  vary  in  degree 
the  quantitative  changes  in  the  color  of  the  skin  do  not  always  have  the 
same  diagnostic  significance. 

Pallor. — The  skin  may  be  pale  by  reason  of  general  or  local  deficiency 
of  blood,  that  is  to  say,  in  consequence  of  anaemia  or  of  contraction  of  the 
capillaries.  The  various  forms  of  anaemia  have  in  common  a  diminution 
in  the  coloring  matter  of  the  blood — oligochromcemia.  Pallor,  even 
when  persistent,  does  not  in  all  instances  justify  a  diagnosis  of  anaemia, 
since  there  are  many  habitually  pale  persons  whose  blood  shows  upon 
examination  a  practically  normal  constitution  both  as  regards  the  erythro- 
cytes and  the  haemoglobin.  Many  such  individuals  present  no  symptoms 
of  constitutional  or  local  disease  and  regard  themselves  as  in  perfect  health. 
The  pallor  in  these  cases  is  due  to  an  abnormality  of  the  skin,  either  an 
unusual  opaqueness  of  the  superficial  layers  or  a  deficiency  in  the  blood 
supply  or  a  combination  of  these  two  conditions.  If  the  conjunctival 
mucous  membrane  and  that  of  the  lips  and  mouth  present  a  normal 
appearance,  the  pallor  is  due  to  the  first  of  these  anomalies.  In  the  major- 
ity of  instances,  however,  marked  and  persistent  pallor  is  associated  with 
other  evidences  of  more  or  less  decided  derangement  of  health.  Even 
under  these  circumstances  in  a  certain  proportion  of  the  cases  the  blood 
shows  no  abnormal  change.  Two  explanations  of  the  pallor  may  be  ad- 
vanced: first,  a  reduction  in  the  total  quantity  of  the  blood,  which  never- 
theless retains  its  constituent  elements  in  normal  proportion;  second,  that 
the  .-kin,  particularly  of  the  face,  as  the  result  of  abnormal  conditions  of 
the  circulation  receives  a  diminished  amount  of  blood.     Since  we  have  no 


542  MEDICAL  DIAGNOSIS. 

clinical  method  of  determining  the  total  volume  of  blood  in  the  body,  the 
first  of  these  explanations  is  purely  theoretical  and  without  practical 
application.  The  second  explanation  finds  support  in  the  constant  presence 
of  other  symptoms  indicative  of  circulatory  derangements,  among  which 
are  a  small  and  feeble  pulse,  general  asthenia,  over-filling  of  the  super- 
ficial veins,  slight  cyanosis,  faintness,  and  dizziness.  The  part  played  by 
enfeeblement  of  the  heart's  action  on  the  one  hand  and  by  vasomotor 
derangements  on  the  other  cannot  in  all  cases  be  satisfactorily  determined. 
Lowered  blood-pressure  does  not  necessarily  induce  pallor,  since  in  this 
condition  the  lumen  of  the  peripheral  vessels  is  widened  and  their  contents 
increased;  but  diminished  blood-pressure  gives  rise  to  pallor  when  the  chief 
factor  in  its  production  is  cardiac  weakness  and  the  vasomotor  tonus  is 
maintained.  Increased  vasomotor  tonus  may  be  the  cause  of  pallor  of 
high  intensity.  Among  the  more  important  diseases  in  which  pallor  occurs 
as  the  result  of  a  diminution  in  the  blood  supply  to  the  vessels  of  the  face, 
without  marked  changes  in  the  composition  of  the  blood,  are  gastrointes- 
tinal affections,  both  acute  and  chronic,  diseases  of  the  heart,  pulmonar}7- 
consumption  and  other  chronic  infections — conditions  ultimately  leading 
to  anaemia  which  in  many  cases  is  profound.  To  this  group  the  transient 
pallor  of  intense  emotion,  nausea,  vertigo,  syncope  and  collapse,  in  which 
vasomotor  derangements  and  cardiac  failure  are  associated  in  the  produc- 
tion of  lowered  blood-pressure,  bears  a  close  etiological  relation.  Indoor 
occupations,  dependence  upon  artificial  light,  mining  and  the  like  cause 
permanent  pallor. 

Clinically  the  following  points  are  important:  (a)  Transient  pallor  is 
caused  by  cardiac  failure,  as  in  nausea,  rigors,  syncope,  and  shock,  or  by 
vasomotor  spasm,  as  in  the  intense  emotions  of  fright,  fear,  anger,  in  pain, 
epilepsy,  and  other  paroxysmal  neuroses.  Transient  pallor  is  frequently 
but  not  always  followed  by  more  or  less  intense  flushing. 

(b)  Sudden  and  more  persistent  pallor  accompanies  hemorrhage,  acute 
poisoning,  and  overwhelming  infection — the  malignant  forms.  Associated 
with  other  symptoms  of  collapse  it  is  a  striking  and  suggestive  sign  of 
internal  hemorrhage,  such  as  may  occur  in  a  large  pulmonary  cavity;  as  the 
result  of  the  rupture  of  an  aortic  aneurism  into  the  pericardial,  pleural,  or 
peritoneal  sac;  in  consequence  of  a  perforating  lesion  in  peptic  ulcer  or 
enteric  fever;  in  rupture  of  the  sac  in  ectopic  gestation,  or  in  concealed 
uterine  hemorrhage  before  or  after  parturition.  Small  hemorrhages  do  not 
necessarily  cause  pallor  except  when  frequently  repeated  or  persistent. 

(c)  Gradually  developing  pallor  is  a  symptom  of  almost  all  serious 
acute  and  chronic  diseases.  In  the  acute  infections  it  usually  passes  off  with 
convalescence;  in  the  chronic  diseases  its  intensity  is  very  often  a  measure 
of  the  gravity  of  the  case.  It  is  sometimes  seen  in  altered  conditions  of 
living,  as  in  the  case  of  young  immigrant  girls  who  during  the  process  of 
acclimatization  not  rarely  permanently  lose  their  color  without  changes  in 
the  blood  or  other  signs  of  ill  health.  The  pallor  in  persistent  slight  hemor- 
rhage, such  as  occurs  in  neglected  hemorrhoids,  is  very  often  intense,  as 
is  the  pallor  of  chlorosis,  pernicious  anaemia,  and  the  secondary  anaemias 
which  occur  in  chronic  poisoning,  chronic  infections,  chronic  suppurative 
processes,  nephritis,  and  valvular  and  mural  disease  of  the  heart. 


SYMPTOMS  AND  SIGNS:    SKIN.  543 

Redness.  —  The  change  in  the  color  of  the  face  is  quantitative. 
It  is  due  to  two  causes:  first,  thinness  and  transparency  of  the  super- 
ficial layers  of  the  integument;  second,  increased  fulness  of  the  capillaries 
—  hyperemia.  An  abnormally  high  haemoglobin  percentage  cannot  of 
itself  be  regarded  as  a  cause  of  the  increased  redness  of  the  complexion. 
Whether  or  not  a  true  plethora  occurs  is  undecided.  Physiologically  we 
find  the  redness  of  the  skin  of  the  face  greater  in  persons  who  live  in  the 
open  air  and  are  especially  exposed  to  sunlight  and  the  wind,  which  increase 
the  cutaneous  circulation.  An  abnormally  transparent  skin  is  the  evident 
cause  of  the  blooming  redness  of  the  cheeks  occasionally  seen  in  chlorotic 
girls—  chlorosis  f.orida.  Very  characteristic  in  these  cases  is  the  contrast 
between  the  color  of  the  skin  and  the  blue-white  conjunctivae.  Among  the 
physiological  causes  of  intensification  of  the  color  of  the  skin  are  powerful 
muscular  effort  and  the  action  of  external  heat,  as  in  hot  baths,  friction  of 
the  surface,  exposure  to  fire  or  heat,  radiation  from  other  sources,  sunburn 
and  the  like.  Extreme  cold  also  produces  cutaneous  hyperaemia  of  the  face. 
Habitual  exposure  to  heat  or  cold,  especially  when  associated  with  moist- 
ure, causes  the  chronic  purplish  hyperaemia  of  the  hands  frequently  seen 
in  washerwomen  and  bartenders  who  are  otherwise  in  good  health. 

Transient  reddening  of  the  skin  dependent  upon  vasomotor  influences 
occurs  under  certain  psychic  influences,  especially  embarrassment  and 
shame.  The  reddening  of  the  skin  in  such  cases  is  not  restricted  to  the  face 
but  may  spread  over  the  throat  and  even  the  upper  part  of  the  chest. 
In  these  latter  situations  it  may  be  irregularly  distributed  in  such  a  way 
as  to  give  rise  to  errors  in  diagnosis  as  regards  actual  disease  of  the  skin,  as 
erythema,  especially  in  sensitive  persons,  and  particularly  in  women  when 
it  is  necessary  to  remove  the  clothing  from  the  upper  part  of  the  body  for 
the  purposes  of  examination.  One-sided  flushing  of  the  face  occurs  in 
certain  forms  of  migraine  and  in  affections  of  the  cervical  sympathetic. 

In  addition  to  the  foregoing  facts  the  flushing  incident  to  pyrexia, 
certain  infections,  and  the  action  of  drugs  deserves  attention. 

Fever. — The  flushing  of  the  skin  in  acute  febrile  conditions  is  very 
characteristic.  It  is  often  attended  with  slight  turgescence  and  sometimes 
with  a  tendency  to  sweat.  The  flush  of  fever  is  usually  widely  distrib- 
uted over  the  surface.  It  is  more  marked  in  young  persons  of  fair  com- 
plexion than  in  older  persons  and  in  brunettes.  It  has  a  tendency  to 
localize  itself  in  the  cheeks  where  it  is  sometimes  circumscribed  or  unilateral, 
as  in  croupous  pneumonia.  Circumscribed  flushing  of  the  cheeks  in  persons 
otherwise  pallid  is  a  very  striking  phenomenon  in  the  hectic  fever  of  ad- 
vanced phthisis.  In  children  the  fever  flush  is  sometimes  so  intense  as  to 
suggest  the  existence  of  erythema  or  scarlatina.  In  rare  instances  pyrexia! 
flushing  occurs  during  the  first  week  of  enteric  fever,  especially  in  young 
persons  of  fair  skin,  and  may  be  so  marked  as  to  give  rise  for  a  time  to 
uncertainty  in  diagnosis. 

Tache  cerebrate  is  a  cutaneous  vasomotor  phenomenon  which  occurs 
especially  in  young  persons  in  acute  febrile  affections,  as  cerebrospinal 
meningitis,  enteric  fever,  and  influenza,  in  certain  functional  nervous 
affections,  as  hysteria,  aeurasthenia,  and  sometimes  in  organic  diseases  of 
the  brain  ami  spinal  cord.      It  is  called    forth    by   slight    irritation   of   the 


544  MEDICAL  DIAGNOSIS. 

skin,  such  as  is  produced  by  tapping  with  the  finger-tip  or  drawing  the 
finger  or  a  pencil  smartly  over  the  surface.  A  white  spot  or  line  appears 
and  is  shortly  followed  by  a  bright  red  discoloration  which  persists  for 
several  minutes. 

Dermatographis?n. — This  condition,  closely  allied  to  the  above,  is  not 
uncommon  in  neurotic  persons,  particularly  in  those  who  suffer  from 
urticaria.  Wheals  may  be  produced  by  drawing  the  finger  or  a  pencil 
somewhat  firmly  over  the  surface.  Letters  and  other  symbols  may  be 
brought  out  in  a  conspicuous  manner  and  often  last  for  several  hours. 
The  itching  characteristic  of  urticaria  does  not  occur. 

Drugs. — The  reddening  of  the  face  caused  by  alcohol  is  of  diagnostic 
importance.  The  expression  "flushed  with  wine"  is  significant.  The 
slightly  turgid,  purplish-red  face  of  chronic  alcoholism,  with  its  distended 
venules,  is  unfortunately  too  familiar.  The  flush  produced  by  the  nitrites 
and  especially  by  the  inhalation  of  amyl  nitrite  resembles  the  blushing  due 
to  psychic  causes.  Flushing  of  the  face  follows  the  administration  of  cer- 
tain poisons,  as  belladonna,  opium,  and  hyoscyamus. 

Cyanosis. — This  term  is  used  to  designate  the  dusky  blue  or  purplish 
color  of  the  skin  dependent  upon  the  circulation  in  the  capillaries  of  blood 
abnormally  rich  in  carbon  dioxide  and  poor  in  oxygen.  Cyanosis  may  be 
general  or  local. 

General  cyanosis  is  dependent  upon  two  factors,  first,  deficient  oxy- 
genation of  the  blood  in  the  lungs,  as  the  result  of  which  the  arterial  blood 
reaches  the  capillaries  containing  less  oxygen  and  darker  in  color  than 
normal;  second,  stasis  in  the  venous  radicals,  resulting  in  an  accumulation 
of  venous  blood  in  the  capillaries  of  the  skin,  which  by  the  retardation  in 
its  flow  becomes  richer  in  carbon  dioxide  and  darker  in  color.  Since  the 
conditions  are  universal  it  may  be  assumed  that  the  bluish  discoloration 
exists  not  only  in  the  skin  but  in  all  the  tissues  of  the  body.  Only  in  its 
intense  forms  does  cyanosis  show  itself  in  all  parts  of  the  surface.  When 
slight  it  appears  in  certain  parts  only  and  here  it  is  in  all  instances  more 
intense  than  elsewhere.  These  regions  are  the  face  and  especially  the  cheeks, 
the  tip  of  the  nose,  the  ears,  lips  and  mucous  surface  of  the  mouth,  which 
have  an  especially  abundant  capillary  circulation  and  translucent  integu- 
ment. Other  points  in  which  cyanosis  is  especially  manifest  are  the  hands 
and  feet,  particularly  the  terminal  phalanges  and  the  nails,  in  which  blood 
stasis  is  favored  by  their  remoteness  from  the  heart. 

The  primary  derangement  may  be  respiratory  or  circulatory.  The 
interdependence  of  the  respiration  and  circulation  is  such,  however,  that 
when  cyanosis  is  marked  there  is  general  derangement  of  both  in  varying 
proportion. 

Respiratory. — All  conditions  which  interfere  with  the  respiratory 
function  and  thus  reduce  the  aeration  of  the  blood  may  give  rise  to  cyanosis. 
They  are  comprised  in  four  groups: 

(a)  All  affections  which  interfere  with  the  access  of  air  to  the  vesicular 
structure  of  the  lungs,  such  as  retropharyngeal  abscess,  stenosis  of  the  larynx 
caused  by  pseudomembranous  exudate,  as  in  diphtheria,  cedema  of  the 
glottis,  pseudocroup,  laryngismus  stridulus,  pertussis,  paralysis  of  the 
abductor  muscles,  tumors  of  the  larynx,  foreign  bodies  in  the  pharynx, 


SYMPTOMS  AND  SIGNS:    SKIN.  545 

larynx,  trachea,  or  bronchi,  all  forms  of  stenosis  of  the  trachea,  including 
thyroid  enlargement  and  other  deep-seated  tumors  of  the  neck,  as  well 
as  mediastinal  and  other  intrathoracic  tumors,  strangulation,  bronchitis, 
and  bronchial  asthma. 

(b)  Affections  which  interfere  with  the  action  of  the  respiratory 
muscles,  including  paralysis  and  atrophy  such  as  occur  in  bulbar  paralysis 
and  peripheral  neuritis;  spasmodic  contraction  of  these  muscles,  as  that  of 
tetanus  or  epilepsy;  painful  affections,  such  as  myalgia,  pleurisy,  and 
peritonitis,  in  which  the  respiratory  movements  are  instinctively  restrained; 
finally,  the  action  of  drugs,  such  as  opium  and  its  preparations,  which 
depress  the  respiratory  centres. 

•  (c)  Affections  which  diminish  the  respiratory  surface.  This  group 
includes  all  forms  of  consolidation  of  the  lung,  croupous  pneumonia,  bron- 
chopneumonia, including  tuberculous  infiltration  and  acute  miliary  tuber- 
culosis, atelectasis,  pressure  atelectasis  from  pleural  and  pericardial  effusion 
and  pneumothorax.  In  emphysema  the  respiratory  surface  is  not  only 
greatly  restricted  but  its  functional  integrity  is  also  impaired. 

(d)  Conditions  in  which  respiratory  movements  are  restricted  and  the 
respiratory  surface  is  circumscribed  by  subdiaphragmatic  pressure,  as  in 
hydramnion,  enormous  ascites,  enlargement  of  the  liver  or  spleen,  or  mas- 
sive abdominal  or  pelvic  tumors. 

Under  all  these  circumstances  the  aeration  of  the  blood  in  the  lungs  is 
diminished  and  venous  stasis  is  favored  by  the  reduction  in  the  normal 
aspiratory  function  of  the  lungs  which  constitutes  an  important  factor  in 
the  circulation.  The  absence  of  cyanosis,  often  observed  in  advanced 
phthisis  with  extensive  destruction  of  the  lungs  and  very  limited  respira- 
tory movement,  is  probably  due  to  the  great  wasting  of  the  body  and  corre- 
sponding reduction  in  the  mass  of  the  blood,  to  the  aeration  of  which  the 
remaining  limited  vesicular  structure  is  still  adequate.  Cyanosis  is  marked 
in  proportion  as  the  interference  with  respiration  is  rapid  and  urgent.  In 
chronic  cases  the  interference  may  reach  a  high  grade  without  causing  cyan- 
osis during  repose,  though  this  symptom  may  appear  upon  slight  exertion. 

Circulatory. — Primary  derangements  of  circulation  which  cause  cyan- 
osis may  be  referred  to  the  following  groups: 

(a)  Affections  of  the  heart  and  arteries,  including  valvular  disease  with 
impaired  or  ruptured  compensation,  myocarditis,  acute  dilatation  of  the 
heart,  the  cardiovascular  changes  which  occur  in  chronic  nephritis,  other 
forma  of  arteriosclerosis,  and  pericarditis. 

In  persistent  foramen  ovale  and  other  forms  of  cardiac  malformation, 
such  as  stenosis  of  the  pulmonary  artery,  there  is  very  often  marked  and 
continuous  cyanosis.  To  this  condition  of  congenital  cyanosis  the  term 
morbus  coervleus  has  been  given.  In  acquired  conditions  permitting  an 
admixture  of  venous  blood  with  arterial  within  the  vessels,  as  in  the  very 
rare  cases  of  aneurism  of  the  aorta  communicating  with  the  vena  cava, 
cyanosis  is  a  suggestive  symptom. 

(b)  Conditions  affecting  the  pulmonary  circulation.  In  disease  of  the 
mitral  valve,  both  stenosis  and  insufficiency,  even  when  compensation  is 
good  there  may  very  often  be  seen,  especially  upon  exertion,  a  slight  degree 
of  cyanosis.    This  is  a  manifestation  of  the  changes  caused  by  the  habitual 

"  35 


546  MEDICAL  DIAGNOSIS. 

increase  of  tension  in  the  pulmonary  circuit  and  the  bronchial  catarrh 
which  to  some  degree  is  almost  constantly  present.  Though  having  its 
primary  cause  in  the  circulatory  apparatus  this  form  of  cyanosis  must  be 
looked  upon  as  respiratory. 

Pressure  upon  the  pulmonary  artery  or  veins  by  massive  pericardial 
effusion,  mediastinal  tumor  or  aneurism  is  a  very  common  cause  of  cyanosis. 
The  circulation  of  the  pulmonary  capillaries  is  obstructed  in  many  of  the 
conditions  involving  the  respiratory  apparatus  which  give  rise  to  cyanosis. 

Blueness  of  the  general  surface,  very  often  intense,  is  produced  by 
overdoses  of  certain  of  the  coal-tar  derivatives,  especially  acetanilid,  by 
nitrobenzole,  and  by  poisoning  with  illuminating  gas. 

Local  cyanosis. results  from  venous  stasis,  from  compression  of  the 
part  or  from  venous  thrombosis.  Cyanosis  of  the  head  and  neck  or  an  upper 
extremity  may  result  from  the  pressure  of  a  tumor  or  aneurism  upon  the 
jugular,  subclavian,  innominate,  or  descending  cava,  the  distribution  of 
the  cyanosis  corresponding  with  the  point  of  pressure.  Similar  cyanosis  of 
one  or  both  lower  extremities  may  result  from  pressure  involving  iliac  veins 
or  the  ascending  vena  cava  or  from  venous  thrombosis.  Local  venous 
thrombosis  giving  rise  to  cyanosis  of  an  arm  is  sometimes  seen  in  cancer 
of  the  breast  with  secondary  implication  of  the  axillary  glands. 

Cyanosis,  often  of  high  grade,  results  from  vasomotor  derangements. 
To  this  cause  must  be  referred  the  cyanotic  discoloration  of  the  extremities 
and  ears  which  follows  exposure  to  intense  cold,  the  cyanosis  of  paralyzed 
members,  and  the  bluish  discoloration  of  the  hands  which  occurs  in  hyster- 
ical and  neurasthenic  persons.  In  the  latter  group  of  cases  the  local  cyanosis 
is  sometimes  associated  with  oedema — the  blue  oedema  of  French  authors. 

Local  cyanosis  is  seen  in  intense  inflammation  involving  the  skin. 

The  conditions  which  give  rise  to  cyanosis,  namely,  retarded  circula- 
tion and  reduced  oxygenation,  interfere  with  the  local  production  of  animal 
heat.  In  cyanosis  the  skin  and  extremities  show  reduction  of  surface 
temperature. 

Jaundice — Icterus. 

These  terms  are  used  to  designate  the  peculiar  pathological  yellow 
discoloration  of  the  skin,  mucous  membranes,  and  fluids  of  the  body  caused 
by  the  circulation  in  the  blood  of  bile  pigment.  The  change  is  qualitative. 
There  are  two  forms,  obstructive  and  toxaemic. 

Obstructive  Jaundice. — This  is  the  more  common  form.  The  dis- 
charge of  bile  into  the  intestine  is  interfered  with  wholly  or  in  part  by 
stenosis  or  closure  of  the  bile  passages.  As  a  result  there  is  resorption  of 
the  bile,  the  pigments  of  which  discolor  the  tissues  in  shades  varying  from 
light  yellow  to  a  dark  brownish-yellow  or  olive-green.  The  darker  shades 
of  jaundice  result  either  from  change  of  the  original  bile  pigments  to  darker 
pigmentary  bodies  or  from  their  excessive  accumulation  in  the  skin.  The 
more  intense  and  darker  forms  of  jaundice  occur  in  protracted  cases.  In 
permanent  obstruction  the  color  may  be  greenish-black  or  bronze — the 
so-called  black  jaundice. 

Among  the  more  important  causes  of  obstructive  jaundice  are  catarrhal 
inflammation   of  the  mucous  membrane  of  the  duodenum  or  the  common 


SYMPTOMS  AND  SIGNS:   SKIN.  547 

duct;  gall-stones  and  parasites,  as  the  round  worm,  in  the  ducts;  stricture  or 
obliteration  of  the  duct;  tumors  developing  in  the  duct  or  exerting  pressure 
upon  its  orifice:  external  pressure  upon  the  duct  by  tumors  of  the  liver, 
stomach,  pancreas,  kidney,  or  omentum,  or  by  enlarged  glands  in  the  porta, 
or  in  rare  instances  by  aneurism  or  fecal  accumulation. 

The  yellow  discoloration  is  observed  first  and,  when  slight,  only  in 
the  conjunctivae  and  the  mucous  membrane  of  the  mouth.  Its  presence 
may  be  detected  by  pressure  upon  the  mucous  membrane  of  the  everted 
lip  with  a  glass  slide,  thus  expressing  the  blood  and  permitting  the  yellow 
stain  of  the  tissues  to  become  apparent.  It  is  sometimes  distinct  at  certain 
pale  areas  of  the  hard  palate.  The  slighter  grades  of  icterus  cannot  be 
recognized  in  artificial  light.  Superficial  resemblances  to  jaundice  are  seen 
in  the  dirty  yellow  or  muddy  discoloration  of  the  malarial  and  malignant 
cachexias.  In  these  conditions  the  absence  of  yellowness  in  the  conjunc- 
tival and  oral  mucous  membranes  is  conclusive.  The  collections  of  yellow 
subconjunctival  fat  occasionally  seen  in  elderly  persons  are  only  in  the 
most  remote  way  suggestive  of  jaundice.  The  yellow  discoloration  which 
occurs  in  picric  acid  poisoning  presents  superficial  resemblances  to  jaun- 
dice.    The  absence  of  bile  pigment  in  the  urine  is  important. 

Pruritus  is  a  troublesome  symptom.  It  is  usually  more  marked  in  the 
chronic  cases.  Lesions  of  the  skin,  the  result  of  scratching,  are  not  uncom- 
mon. Sweating  is  common  and  may  be  localized.  Urticaria,  furuncles, 
lichen,  xanthelasma,  and  other  diseases  of  the  skin  occur.  In  some  of  the 
chronic  cases  circumscribed  patches  of  dilatation  of  the  capillary  vessels 
and  minute  arteries — telangiectasis — develop  in  the  skin  of  the  face  and 
body  and  occasionally  upon  the  mucous  membranes.  In  protracted  and 
severe  cases  there  may  be  hemorrhages  into  the  skin,  usually  in  the  form 
of  purpuric  spots  upon  the  lower  extremities,  but  sometimes  as  large 
ecchymoses,  and  in  some  instances  spontaneous  bleeding  from  the  mucous 
membranes  occurs.  The  blood  in  chronic  jaundice  coagulates  very  slowly — 
ten  to  twelve  minutes,  instead  of  about  four  in  the  case  of  normal  blood — 
and  troublesome  and  even  fatal  hemorrhage,  usually  in  the  form  of  uncon- 
trollable capillary  oozing,  may  follow  operation  or  injury.  The  sweat  is 
bile-stained  and  discolors  the  clothing.  The  urine  contains  bile  pigment 
and  may  show  the  color  reaction  to  Gmelin's  test  before  the  yellow  tint 
appears  in  the  mucous  membranes  or  the  skin.  The  color  varies  from  light 
yellow  with  a  greenish  tinge  to  a  deeply  opaque  black-green.  In  intense  or 
long-standing  jaundice  the  urine  commonly  contains  albumin  and  tube 
casts  which  are  bile-stained.  Upon  agitation  the  dark  urine  of  jaundice  is 
frothy  and  is  often  popularly  compared  to  porter.  The  sputa  are  not  often 
bile-stained,  except  when  pneumonia  is  present.  On  the  other  hand  the 
saliva  very  rarely  shows  the  yellow  discoloration,  which  is  likewise  absent 
in  the  tears  and  milk. 

As  no  bile  is  discharged  into  the  intestine  the  stools  are  of  a  pale  drab 
or  clay  color.  They  are  usually  pasty  and  very  fetid.  The  absence  of  bile 
in  the  faeces  is  of  importance  in  the  differential  diagnosis  between  obstruc- 
tive and  toxaemic  jaundice.  Commonly  there  is  constipation;  occasionally 
diarrhoea.  The  pulse,  in  obstructive  jaundice  especially,  in  recent  cases  ie 
usually  slow  and  may  fall  to  30  or  lower.    The  frequency  of  the  respiration 


548  MEDICAL  DIAGNOSIS. 

is  also  diminished,  in  some  instances  to  10  or  8  per  minute.  The  tem- 
perature may  be  subnormal.  These  symptoms  are  attributed  to  the 
action  of  the  biliary  salts,  which  undergo  resorption  together  with  the 
bile  pigment.  They  are  not  constant  and  when  present  not  necessarily 
unfavorable. 

The  patient  is  usually  depressed  and  irritable.  In  severe  cases  melan- 
cholia may  develop.  The  liability  to  the  occurrence  of  the  condition  called 
cholaemia  constitutes  a  serious  danger  in  persistent  jaundice.  The  patient 
falls  into  the  so-called  typhoid  state,  with  fever,  rapid  pulse,  dry  tongue, 
and  muttering  delirium.  Convulsions  and  coma  develop  and  rapidly  prove 
fatal.  This  group  of  symptoms  resembles  uraemia.  They  have  been  attrib- 
uted to  poisoning  by  cholesterin — cholestersemia.  The  toxic  substances 
have  not  been  determined. 

Toxaemic  Jaundice. — The  jaundice  is  associated  with  the  presence  of 
various  poisons  in  the  blood  which  act  directly  upon  the  red  blood-corpuscles 
and  in  some  cases  upon  the  liver-cells.  Among  these  poisons  are  (a)  snake 
venom,  phosphorus,  arsenic,  chloral  hydrate,  chloroform,  and  ether;  (b) 
toxins  elaborated  within  the  organism  in  the  course  of  the  specific  infec- 
tious diseases,  as  yellow  fever,  relapsing  fever,  malaria,  pneumonia,  enteric 
fever,  typhus,  and  scarlatina;  (c)  the  toxins  of  septic  conditions,  pyaemia, 
malignant  endocarditis,  acute  yellow  atrophy  of  the  liver,  Weil's  disease, 
and  epidemic  jaundice.  The  symptoms  are  generally  less  intense  than  in 
obstructive  jaundice.  The  discoloration  of  the  skin  is  usually  slight; 
exceptionally,  as  in  the  case  of  acute  yellow  atrophy  and  malignant  jaun- 
dice, it  is  intense.  The  stools  are  colored  with  bile,  sometimes  deeply. 
The  urine  may  be  dark  from  increase  in  the  normal  urinary  pigments  but 
gives  little  or  no  reaction  for  bile  pigment.  Toxic  jaundice  of  slight  degree 
frequently  appears  during  the  course  of  febrile  affections  and  under  other 
circumstances  and  may  be  without  unfavorable  prognostic  significance. 
On  the  other  hand  in  many  cases  the  conditions  in  which  this  form  of 
jaundice  occurs  are  attended  with  profound  constitutional  disturbance, 
manifest  in  intense  fever,  delirium,  suppression  of  urine,  hemorrhages  into 
the  skin  and  from  mucous  surfaces,  convulsions  and  coma,  and  very  often 
terminate  in  death. 

The  jaundice  due  to  obstructive  changes  in  the  bile  passages  was 
formerly  spoken  of  as  hepatogenous;  toxaemic  jaundice  as  hematogenous. 
Concerning  the  mode  of  origin  of  toxaemic  jaundice  there  is  much  diversity 
of  opinion  and  the  cases  differ  among  themselves.  In  groups  of  cases  there 
is  probable  resorption  of  bile  pigments  from  the  liver  as  the  result  of  patho- 
logical processes  involving  the  finer  ducts  or  the  liver  parenchyma  itself. 
Some  pathologists  attribute  the  icterus,  so  common  in  pneumonia,  to  a 
catarrh  of  the  finer  bile  passages  dependent  upon  venous  stasis,  while  others 
attribute  it  in  part  at  least  to  the  interference  with  the  respiratory  move- 
ment of  the  diaphragm  caused  by  the  consolidation  of  the  lung,  and  result- 
ing in  an  accumulation  in  the  smaller  ducts  of  bile  which  undergoes  resorp- 
tion. The  rapid  course  and  profound  disorganization  of  the  liver  in  acute 
atrophy  and  in  phosphorus  poisoning  suggest  the  possibility  that  other 
forms  of  grave  toxaemic  jaundice  may  be  due  to  as  yet  unknown  paren- 
chymatous changes  in  the  liver.     On  the  other  hand  most  of  the  poisons 


SYMPTOMS  AND  SIGNS:   SKIN.  549 

which  cause  icterus  exert  a  destructive  influence  upon  the  erythrocytes. 
It  has  been  shown  experimentally,  however,  that  the  yellow  pigment  in 
poisoning  by  certain  substances,  as  toluylendiamine,  is  not  formed  in  the 
blood  but  in  the  liver,  the  haemoglobin  being  transformed  into  biliary 
pigment  in  that  organ.  As  a  result  of  this  transformation  the  bile  pigments 
accumulate  in  the  liver  in  such  quantity  that  they  cannot  be  wholly  excreted, 
a  certain  portion  undergoing  resorption.  In  consequence  of  these  facts 
the  term  hamatohepatogenous  has  been  suggested  for  this  form  of 
jaundice.  In  the  present  state  of  knowledge  the  etiological  designation 
toxsemic  jaundice  is  to  be  preferred.  The  term  toxa?mic-obstructive  jaun- 
dice has  been  suggested  by  Hunter. 

Normal  and  Abnormal  Pigmentation — Melanoderma. — The  physiological 
pigmentation  of  the  skin  shows  wide  variations  not  only  in  different  races 
but  in  different  individuals  of  the  same  race.  Among  the  fair-skinned  a 
blonde  and  a  brunette  type  are  recognized.  The  latter  is  characterized  by  a 
darker  color  of  the  hair,  skin,  and  iris.  Normally  the  skin  is  more  deeply  pig- 
mented in  the  exposed  portions  of  the  body  to  which  the  light  and  air  have 
free  access  than  elsewhere;  upon  extensor  than  upon  flexor  surfaces  in 
the  region  of  the  joints;  and  about  the  nipples,  linea  alba,  and  genital  or- 
gans. During  pregnancy  the  pigmentation  in  these  latter  situations  is 
greatly  increased,  especially  in  brunettes,  and  upon  the  face  and  in  other 
portions  of  the  body  there  are  occasionally  seen  irregular,  abnormally  pig- 
mented areas  known  as  chloasma  gravidarum — masque  des  femmes  enceintes. 
Patchy  pigmentation  of  the  skin  is  a  common  symptom  of  uterine  disease. 
In  sedentary  persons  of  constipated  habit  irregular  patchy  pigmentation 
of  the  skin  is  common,  especially  about  the  face  and  eyes. 

Freckles  or  ephelides  are  another  physiological  pigmentation  of  the 
skin  without  diagnostic  importance.  The  pigmentation  appears  in  cir- 
cumscribed spots  varying  from  one  to  several  millimetres  in  diameter, 
chiefly  upon  the  face,  but  also  in  other  parts  of  the  body,  especially  the 
backs  of  the  hands  and  arms.  They  are  more  common  in  fair  than  dark 
persons  and  are  almost  always  present  in  individuals  with  red  hair.  The 
spots  are  more  abundant  and  the  pigmentation  deeper  in  summer  than  in 
winter,  when  they  sometimes  wholly  disappear. 

The  pigmentation  following  measles  and  showing  the  characteristic 
form  and  arrangement  of  the  eruption  is  not  wholly  without  interest  to  the 
clinician,  and  the  localized  pigmentation  which  follows  the  application  of 
sinapisms  and  blisters  deserves  passing  mention. 

The  vagabond's  skin  is  If'torm  applied  to  the  diffuse  pigmentation 
resulting  from  lousiness  and  dirt  and  the  scratching  caused  by  these  condi- 
tions. The  pigmentation  sometimes  reaches  a  very  high  grade.  It  may 
be  arranged  in  a  very  characteristic  manner  in  snipes  corresponding  to  the 
lines  of  scratching.  This  condition  has  been  confounded  with  the  pig- 
mentation <>f  Addison's  disease. 

MELANOSARCOMA,  especially  when  generalized,  very  often  produces  a 
deep  ami  widespread  cutaneous  pigmentation.  Under  these  circumstances 
in  exceptional  cases  the  urine  also  contains  abnormal  pigment. 

In  ADVANCED  PULMONARY  TUBERCULOSIS  a  Striking  brownish  discol- 
oration of  the  face  or  the  whole  body  is  sometimes  observed. 


550  MEDICAL  DIAGNOSIS. 

In  abdominal  new  growths,  especially  cancer  or  lymphoma,  diffuse 
cutaneous  pigmentation  occasionally  occurs.  It  is  not  uncommon  in  tuber- 
culosis of  the  peritoneum. 

In  HiEMACHROMATosis,  such  as  occurs  in  hypertrophic  cirrhosis,  dia- 
betes, and  other  conditions,  pigmentation  of  the  skin  may  be  present. 

Exophthalmic  goitre  maybe  associated  with  abnormal  pigmentation. 

Gastric. — In  rare  instances  diffuse  pigmentation  attends  gastric  ulcer 
and  dilatation. 

In  scleroderma  cutaneous  pigmentation  may  be  general  and  of 
high  grade. 

Cardiac. — In  chronic  disease  of  the  heart  and  arteriosclerosis  diffuse 
pigmentation  may  occur. 

Addison's  Disease. — The  bronze  discoloration  of  this  affection  is 
clinically  the  most  important  form  of  abnormal  pigmentation  of  the  skin. 
It  usually  shows  itself  first  upon  exposed  surfaces,  as  the  hands  and  face, 
and  is  more  intense  in  those  regions  in  which  the  skin  is  normally  more 
deeply  colored  than  elsewhere.  It  begins  as  a  faint  smoke-gray  discolora- 
tion and  progressively  deepens  to  an  intense  bronze  or  mulatto  hue.  In 
the  diffuse  smoky  coloration  isolated  intense  dark  brown  points  may  be 
distinguished.  The  grayish  pigment  patches  seen  upon  the  mucous  mem- 
brane of  the  mouth  are  characteristic  of  Addison's  disease.  The  palms  and 
soles  as  well  as  the  nails  commonly  remain  pigment  free.  The  discolora- 
tion of  Addison's  disease  may  suggest  intense  jaundice,  but  the  general 
condition,  the  yellow  staining  of  the  conjunctivae  and  the  mucous  mem- 
brane of  the  mouth,  and  the  presence  of  bile  pigment  in  the  urine  are  of 
positive  diagnostic  importance. 

Hepatic  Disease. — The  peculiar  discoloration  of  the  skin  occasion- 
ally seen  in  cirrhosis  and  other  diseases  of  the  liver  demands  consideration. 
The  color  is  a  dirty  brownish-gray.  It  is  to  be  differentiated  from  icterus 
by  the  color  itself,  the  absence  of  staining  of  the  mucous  membranes,  and 
the  condition  of  the  urine.  This  pigmentation  is  of  especial  interest  in 
connection  with  the  bronzing  of  the  skin  that  occurs  in  certain  cases  of 
diabetes — diabete  bronze — developing  late  in  hsemachromatosis  and  asso- 
ciated with  pigmentary  cirrhosis  of  the  liver  and  pancreas.  The  color 
suggests  Addison's  disease,  but  the  presence  of  grape  sugar,  the  physical 
signs  of  hepatic  cirrhosis  without  jaundice,  and  the  absence  of  the  char- 
acteristic symptoms  of  Addison's  disease  are  of  diagnostic  importance. 

Arsenomelanosis. — The  pigmentation  of  the  skin  produced  by  the 
prolonged  administration  of  arsenic  in  full  doses  sometimes  presents  a  very 
close  resemblance  to  Addison's  disease.  In  a  majority  of  the  cases  it 
entirely  disappears  when  the  drug  is  withheld;  exceptionally  it  is  persistent. 
It  is  important  to  know  that  in  some  instances  the  pigmentation  of  the  skin 
has  followed  the  use  of  arsenic  in  moderate  doses. 

Argyria. — The  prolonged  administration  of  silver  nitrate  results  in 
the  deposition  of  particles  of  metallic  silver  or  its  albuminate  in  the  internal 
organs  and  in  the  skin.  The  resulting  discoloration  is  a  peculiar  bluish- 
gray  which  is  more  intense  upon  the  face  and  hands  and  is  not  changed  by 
pressure.  The  discoloration  may  be  observed  in  the  mucous  membrane 
of  the  mouth.     It  is  persistent  and  not  amenable  to  treatment. 


SYMPTOMS  AND  SIGNS:   SKIN.  551 

Albinism  is  a  term  used  to  designate  developmental  deficiency  of  pig- 
ment. In  albinos  the  skin,  hair,  and  eyes  are  conspicuous  by  the  absence 
of  pigment.  The  affection  may  be  partial  or  universal.  It  is  frequently 
associated  with  other  developmental  defects,  especially  coloboma.  Nys- 
tagmus is  common. 

Vitiligo  is  a  condition  of  the  skin  characterized  by  deficienc}'  of  pig- 
ment. The  patches  are  usually  circumscribed,  very  often  distinctly  margi- 
nate,  and  sometimes  surrounded  by  a  zone  of  pigmentation  slightly  deeper 
than  normal.  It  may  occur  on  any  part  of  the  body,  but  is  common  on  the 
back  of  the  neck  and  shoulders,  the  abdomen,  and  scrotum.  There  are  no 
subjective  symptoms.    It  occurs  in  adolescents  and  young  adults. 

Leucoderma  or  pigment  atrophy,  usually  circumscribed  or  irregularly 
distributed,  is  encountered  in  exophthalmic  goitre,  myxcedema,  sclero- 
derma, and  other  constitutional  disturbances. 

Moisture. — There  are  wide  variations  in  the  activity  of  the  sweat- 
glands  within  physiological  limits.  Perspiration  is  excited  by  those  causes 
which  determine  an  active  blood  supply  to  the  skin.  It  is  therefore  more 
abundant  in  warm  weather,  after  exercise,  hot  baths,  and  hot  drinks.  An 
outburst  of  sweating  may  occur  in  connection  with  sudden  intense  emotion. 
A  pathological  increase  of  perspiration  is  termed  hyperidrosis ;  its  absence 
anidrosis.  These  terms  are  commonly  used  to  designate  conditions  in  which 
the  increase  or  absence  are  persistent  or  habitual. 

Hyperidrosis. — Free  perspiration  attends  certain  febrile  diseases, 
especially  rheumatic  fever,  some  cases  of  enteric  fever,  acute  polyneuritis, 
miliary  fever,  and  septic  conditions.  A  critical  decline  of  fever,  whether 
spontaneous  or  the  result  of  the  administration  of  antipyretics,  is 
almost  always  attended  by  more  or  less  abundant  sweating.  Perspiration 
is  one  of  the  processes  by  which,  both  physiologically  and  pathologically, 
the  temperature  of  the  body  is  lowered.  Profuse  sweating  attends  the 
crisis  in  pneumonia,  relapsing  fever,  and  typhus.  Sweating  is  often  abund- 
ant toward  the  close  of  enteric  fever  when  the  temperature  curve  assumes 
a  distinctly  remittent  or  intermittent  type.  The  fall  of  temperature  in  the 
ague  paroxysm  is  almost  always  attended  with  copious  sweating.  That 
of  the  hectic  fever  of  phthisis  and  other  wasting  diseases  usually  occurs 
during  the  night  or  toward  morning.  It  is  attended  with  abundant  sweat- 
ing—  night-sweats  —  and  is  of  unfavorable  prognostic  significance.  Pro- 
fuse sweating  occurs  in  some  cases  of  phthisis  in  the  absence  of  fever. 
Sudden  abundant  sweats  are  accompanied  by  sensations  of  great  weakness 
and  prostration  which  are  in  part  due  to  the  relaxation  of  the  vessels  fol- 
lowing the  sudden  withdrawal  of  fluid.  Excessive  sweating  occurs  in  the 
convalescence  from  some  diseases.  It  occurs  in  collapse,  urgent  dyspnoea, 
and  sometimes  accompanies  severe  paroxysms  of  pain.  In  rare  instances 
of  diabetes  abundant  perspirations  have  alternated  with  polyuria.  In- 
creased sweating  sometimes  attends  the  suppression  of  urine  that  occurs 
in  certain  forms  of  nephritis.  Under  these  circumstances  crystals  of  urea 
may  accumulate  upon  the  skin  and  especially  upon  the  face. 

[vocalized  sweating  is  not  uncommon  in  pathological  conditions. 
Hyperidrosis  of  the  hands  and  feel  occasionally  occurs  in  neurotic  individu- 
als  and   sometimes   in    persons   otherwise   healthy.      The   condition   is   very 


552  MEDICAL  DIAGNOSIS. 

annoying.  The  sweat  is  usually  copious  and  foul-smelling.  Axillary  sweat- 
ing :.s  an  annoying  constitutional  peculiarity.  Sweating  of  the  head, 
especially  during  sleep;  is  an  important  symptom  in  rickets.  Unilateral 
sweating  of  the  head  or  face  occurs  in  certain  nervous  diseases,  as  migraine 
and  neuralgia,  and  may  result  from  pressure  upon  the  sympathetic  by  a 
thoracic  aneurism  or  mediastinal  tumor.  Localized  sweating  depends 
upon  vasomotor  derangements.  Diaphoresis  follows  the  administration 
of  certain  drugs,  especially  ammonium  acetate,  pilocarpine,  and  many  of 
the  coal-tar  derivatives. 

Anidrosis. — Abnormal  dryness  of  the  skin  occurs  under  conditions  in 
which  an  excess  of  fluid  is  withdrawn  from  the  body  by  way  of  its  internal 
surfaces,  or  very  little  water  reaches  the  blood  by  way  of  the  gastrointes- 
tinal tract — for  example,  profuse  diarrhoea,  continuous  vomiting,  diabetes 
mellitus  and  insipidus,  chronic  nephritis  with  polyuria,  and  the  deprivation 
of  fluid.  The  dry  skin  of  myxcedema  and  general  anasarca  is  largely  attrib- 
utable to  the  interference  with  the  cutaneous  circulation  resulting  from 
tension. 

Modifications  in  the  Perspiration. — Perspiration  when  abundant  usually 
has  a  peculiar  acid  odor.  That  in  rheumatic  fever  is  acid  and  ill- 
smelling;  the  sweat  of  the  hands,  feet,  and  axilla  is  almost  always  foul; 
that  in  certain  forms  of  nephritis  has  a  urinous  odor.  The  sweat  may  be 
discolored — chromidrosis — yellow  from  biliary  pigments  in  jaundice;  blue 
from  the  action  of  the  Bacillus  pyocyaneus.  There  are  instances  recorded 
of  the  sweating  of  a  blood-stained  fluid  or  blood  in  hysterical  females — 
hcematidrosis — and  there  exists  a  term — menidrosis — to  describe  vicarious 
menstruation  by  way  of  the  skin.  These  conditions  are  of  no  importance 
in  diagnosis.  Various  colored  perspiration-stains  upon  the  linen  are  not  to 
be  mistaken  for  instances  of  chromidrosis.  It  may  prevent  error  to  call 
attention  to  the  fact  that  some  of  the  aniline  dyes  undergo  more  or  less 
marked  changes  in  color  under  the  action  of  perspiration. 

Fulness  of  the  Skin — Turgor. — The  normal  appearance  of  fulness 
of  the  skin  is  due  to  the  blood  and  lymph  in  its  vascular  and  lymph  spaces. 
It  varies  in  different  individuals  and  in  different  parts  of  the  body,  and  is 
more  pronounced  in  females.  In  connection  with  an  abundant  panniculus 
it  has  much  to  do  in  causing  the  condition  described  by  the  French  as 
embonpoint.  Increased  fulness  of  the  skin  is  seen  in  fever  and  other  con- 
ditions attended  by  active  cutaneous  circulation;  decreased  fulness  in  all 
conditions  in  which  the  cutaneous  circulation  is  diminished  without  stasis, 
particularly  in  emaciation,  the  cachexias,  and  under  the  deprivation  of 
fluid.  Increased  fulness  is  manifested  by  rounding  of  the  contours,  espe- 
cially those  of  the  face,  and  usually  by  a  deeper  color  of  the  skin,  while 
diminished  fulness  produces  accentuation  of  the  angles  and  is  usually 
associated  with  more  or  less  pallor.  In  the  former  condition  the  skin  is 
smooth,  soft,  and  elastic;  when  pinched  up  into  folds  it  rapidly  reassumes 
its  normal  surface.  In  the  latter  such  folds  only  slowly  disappear.  Normal 
fulness  or  turgor  is  to  be  distinguished  from  oedema  and  anasarca  by  the 
pathological  amount  of  fluid  in  the  skin  in  the  latter,  the  loss  of  the  normal 
cutaneous  elasticity,  and  by  the  persistence  of  the  pitting  made  by  pressure 
of  the  finger.     The  difference  between  "looking  well"  and  "looking  bad" 


SYMPTOMS  AND  SIGNS:   SKIN. 


553 


(Edema  in  chronic  parenchym- 
atous nephritis. — Jefferson  Hospital. 


very  often  depends  upon  slight  transient  variations  in  the  normal  fulness 
of  the  face,  which  is  diminished  in  conditions  of  exhaustion  and  depression 
and  increased  after  repose  and  in  pleasur- 
able excitement.  The  turgor  of  the  skin 
is  usually  increased  in  exophthalmic  goitre. 
Greatly  diminished  fulness  of  the  skin  such 
as  occurs  in  ileus,  peritonitis,  cholera,  and 
some  cases  of  shock,  and  which  precedes 
death,  gives  rise  to  the  facies  Hippocratica 
seen  in  these  conditions. 

(Edema — Dropsy. — An  abnormal  accu- 
mulation of  serous  fluid  collects  in  the  lymph 
spaces  of  the  skin  and  the  subcutaneous    Fig.  201a 
connective  tissue  as  the  result  of  a  disturb- 
ance of  the  balance  between  the  fluid  which  transudes  from  the  capillaries  and 
that  which  is  taken  up  by  the  lymphatics.     This  disturbance  of  balance  may 

be  due  to  (a)  venous  obstruction, 
(b)  altered  condition  of  the  blood 
—  hydrcemia,   (c)    inflammation, 
and  (d)  ceclema  of  nervous  ori- 
gin.    The  diagnostic  significance 
of    oedema    depends    upon    its 
location,   extent,    and    mode   of 
development  and  its  causal  rela- 
tions to  local  or  constitutional 
diseases.     General  cedema  is  de- 
scribed under  the  term  anasarcd. 
The  skin  is  distended   and   the 
normal  surface  landmarks  oblit- 
erated.   When  cedema  is  marked 
the  surface  is  tense,  pallid,  and 
glistening.       In    rapidly    devel- 
oping recent  cedema   it    has   a 
translucent   appearance.      In 
some  surfaces,   especially   upon 
the  abdomen  and  thighs,  trans- 
parent  parallel  stripes    appear, 
similar    to    those    seen    on    the 
abdomen  in  pregnancy.     These 
are  due  to  the  collection  of  the 
fluid  in  the  lines  of  separation 
of   the  distended    tissues   or   in 
the  enlarged  lymphatic  spaces. 
They    usually    disappear    upon 
the  subsidence   of   the  oedema 
without  Leaving  traces.     Occa- 
sionally   they   leave   permanent    irregular    linear    scars.     In    oedema    of 
high  grade,  especially   under   the   influence   of   irritation   or  Blight   trau- 
matism of  the  skin,  blebfl   may  form   upon  the  epidermis  which   rupture 


l  !<■   201b     -(Edema    <>i    tin-    legs    with    cutaneous 
bleba  in  a  case  'if  subacute  parenchymatous  nephritis. — 
ii  Hospital. 


554 


MEDICAL  DIAGNOSIS. 


and  are  followed  by  the  discharge  of  serous  fluid.  Occasionally,  espe- 
cially upon  the  legs  and  ankles,  transudation  of  the  flu'd  takes  place 
through  minute  openings  of  the  skin  without  bleb  formation.  Under 
these  circumstances  infection  may  occur,  giving  rise  to  erysipelatous 
or  other  inflammation.  The  pale  color  of  the  skin  in  cedema  is  caused 
by  diminished  capillary  circulation  from  compression.  The  cedematous 
parts  are  sometimes  cyanosed  and  in  inflammatory  cedema  the  skin 
is  reddened. 

The  normal  elasticity  of  the  skin  is  impaired  by  tension  and  the  inhibi- 
tion of  fluid.  Pressure  upon  the  cedematous  part  gives  rise  to  pitting  which 
only  slowly  disappears.  Where  the  skin  is  normally  distensible  and  elastic 
the  pitting  is  more  transient.     This  is  especially  the  case  in  children.     In 


Fig.  202. 


-CEdema  of  abdominal  wall  and  thighs  in  ascites  due  to  atrophic  cirrhosis  of  the  liver. — Jefferson 

Hospital. 


moderate  cedema  of  long  standing  a  gradual  increase  in  the  subcutaneous 
connective  tissue  develops  and  pitting  is  less  marked  and  more  transient. 

(a)  Venous  Obstruction-. — Factors  in  the  production  of  this  form  of 
cedema  are  diminished  general  muscular  activity,  impaired  pumping  action 
of  the  organs  of  respiration,  diminution  of  the  aspiratory  force  of  the  heart 
in  diastole  and  positive  pressure  on  the  veins.  Coincidently  the  return 
flow  of  the  lymph  which  is  brought  about  by  the  same  forces  that  maintain 
the  venous  circulation  is  impeded.  This  form  of  dropsy  is  frequently  asso- 
ciated with  effusion  into  the  great  serous  sacs.  The  fluid  which  collects  is 
clear,  usually  colorless,  of  low  specific  gravity,  fibrin  free,  and  contains  a 
slightly  smaller  amount  of  proteids  than  the  blood- serum.  It  is  to  be 
distinguished  from  an  inflammatory  exudate  which  is  often  turbid,  some- 
times bloody,  of  high  specific  gravity,  and  usually  contains  masses  of  fibrin. 
Changes  in  the  tissues  and  particularly  in  the  endothelium  of  the  lymph- 
spaces  also  play  an  important  part  in  cedema-formation — so-called  "vital 
secretory"  processes. 

The  collection  of  serous  fluid  in  the  pericardium  is  known  as  hydroperi- 


SYMPTOMS  AND  SIGNS:    SKIN. 


cardium,  in  the  pleural  cavity  as  hydrothorax,  in  the  peritoneal  cavity  as 
hydroperitoneum  or  ascites,  in  the  brain  as  hydrocephalus,  in  the  joints  as 
hydrarthrosis.  Any  of  the  affections  of  the  heart  and  lungs  which,  by  inter- 
fering with  the  return  of  the  venous  blood,  cause  cyanosis  may  also  cause 
oedema.  Cyanosis  and  oedema  are  therefore  frequently  associated.  This 
form  of  oedema  appears  earliest  and  reaches  its  fullest  development  in  those 
regions  in  which  the  circulation,  by  reason  of  remoteness  from  the  heait 
and  the  influence  of  gravity,  is  less  active,  as  in  the  extremities  and  the 
lumbar  regions  and  other  dependent 
portions  in  bedridden  patients.  The 
face  at  first  is  free  and  becomes 
cedematous  only  when  the  anasarca 
reaches  a  high  grade.  Gravity  plays 
an  important  part  in  the  localization 
of  the  oedema.  (Edema  of  the  legs 
and  feet  while  the  patient  is  in  the 
upright  position  may  alternate  with 
oedema  of  the  back  and  thighs  when 
he  is  in  the  recumbent  posture.  The 
patient  who  is  apparently  free  from 
oedema  while  in  bed  may  show 
oedema  of  the  feet  and  ankles  when 
he  first  rises.  In  prolonged  main- 
tenance of  the  lateral  decubitus  the 
oedema  is  more  marked  upon  the  de- 
pendent side.  In  anasarca  of  high 
grade,  partly  on  account  of  their 
dependent  position  and  partly  on  ac- 
count of  the  distensibilityof  the  skin, 
the  penis  and  scrotum  and  the  labia 
majora  become  enormously  swollen. 

Local  oedema  may  be  due  to 
the  obstruction  of  a  venous  trunk  by 
thrombosis  or  pressure.  (Edema  of 
the  arm  from  the  pressure  of  enlarged 
axillary  lymphatics  upon  the  veins, 
and  the  oedema  of  the  leg  in  throm- 
bosis of  the  femoral  vein  are  familiar  examples.  Obstructive  oedema  of  the 
lower  extremities  is  frequently  secondary  to  peritoneal  effusion,  such  as 
results  from  cirrhosis  or  portal  thrombosis  or  from  chronic  peritonitis. 
The  accumulation  of  the  fluid  presses  upon  the  inferior  vena  cava  or  the 
common  iliac  veins.  In  other  cases  the  oedema  of  the  lower  extremities 
and  the  peritoneal  effusion  are  due  to  the  same  cause.  When,  upon  investi- 
gation, the  signs  of  peritoneal  effusion  are  found  to  have  preceded  the 
oedema  of  the  limbs,  the  Latter  condition  is  usually  secondary. 

(b)  Altered  Condition  of  the  Blood  Hydraemia.  A  watery  condition  of 
the  blood  is  a  common  cause  of  oedema  and  other  forms  of  dropsy.  To  t  his 
condition  may  !><■  referred  those  forms  of  oedema  which  occur  in  nephritis, 
chronic  wasting  diseases,  the  anaemias,  and  cachexias.     Nb1  infrequently 


Fro.  203 


GEdema  of  left  leg  due  t< 

the  external  iliac  vein. — German  Hospital 


romuua  in 


556  MEDICAL  DIAGNOSIS. 

associated  cardiovascular  disorders  are  present  which  interfere  with  the 
venous  circulation,  and  in  such  cases  the  oedema  from  venous  obstruction 
and  the  cedema  of  hyclraemia  are  combined.  This  form  of  oedema  differs 
markedly  from  the  cedema  of  venous  obstruction  in  its  early  localization, 
which  is  dependent  much  less  upon  remoteness  from  the  heart  and  the  action 
of  gravity  and  much  more  upon  the  peculiarities  of  the  lymph  structures. 
It  is  characteristic  of  the  cedema  of  certain  forms  of  nephritis  that  it  first 
appears  in  the  face  and  especially  about  the  eyelids.  With  this  early  oedema 
of  the  face  pretibial  cedema  is  often  associated  and  is  sometimes  present 
in  cases  of  nephritis,  especially  the  chronic  interstitial  forms  in  which  facial 
cedema  is  slight  or  absent  altogether.  The  cedema  of  acute  nephritis  often 
develops  rapidly  and  reaches  a  very  high  grade.  Not  infrequently  it  is 
associated  with  effusion  into  the  serous  sacs.  In  that  form  of  nephritis 
characterized  by  contraction  of  the  kidney  cedema  is  very  often  slight  in 
amount  and  a  late  manifestation,  first  showing  itself  when  the  hyper- 
trophied  heart  begins  to  fail.  In  the  subacute  and  chronic  forms  of  paren- 
chymatous nephritis  the  cedema  is  usually  moderate,  showing,  however, 
temporary  increases  which  accompany  exacerbations  of  the  disease.  In 
the  hyclraemia  resulting  from  large  or  frequently  repeated  hemorrhage, 
cedema  is  often  pronounced.  (Edema  of  the  feet  and  ankles  is  a  very 
unfavorable  symptom  in  pulmonary  consumption.  Occurring  in  the  ab- 
sence of  renal  disease  or  especially  in  the  absence  of  conditions  giving  rise 
to  venous  obstruction  it  is  commonly  an  indication  of  approaching  death. 

(c)  Inflammatory  (Edema. — The  local  cedema  in  the  region  of  in- 
flammatory and  suppurative  processes  is  of  diagnostic  importance.  It 
is  sometimes  known  as  collateral  cedema.  The  color  of  the  surface 
varies  from  a  faint  blush  to  a  deep,  mottled,  cyanotic,  purplish  red. 
It  is  due  to  obstruction  of  the  lymph  circulation  by  the  inflammatory 
exudate.  In  some  instances  it  appears  to  be  caused  by  an  accumulation 
of  the  fluid  part  of  the  exudate  in  the  tissues  surrounding  the  inflammatory 
focus.  It  occurs  in  the  region  behind  the  ear  in  mastoid  disease;  about  the 
angle  of  the  jaw  in  mumps  and  parotid  bubo;  at  the  base  of  the  thorax  in 
empyema.  It  is  an  important  sign  of  hepatic  abscess,  acute  suppurative 
gall-bladder  disease,  and  is  sometimes  seen  in  the  right  lower  quadrant  of 
the  abdomen  in  appendicular  abscess.  It  constitutes  the  so-called  collar 
of  brawn  in  severe  anginose  scarlatina. 

(d)  (Edema  of  Nervous  Origin. — The  rare  cases  of  sudden  transitory 
cedema  of  the  face  and  neck,  sometimes  associated  with  symptoms  of  cedema 
of  the  respiratory  or  gastro-intestinal  mucous  membranes,  must  be  ascribed 
to  angioneurotic  derangements.  The  mechanism  which  causes  it  remains 
unknown.  The  condition  known  as  angioneurotic  cedema  is  characterized 
by  the  sudden  occurrence  of  local  cedematous  swellings  of  transient  duration 
upon  the  face,  hands,  and  elsewhere.  Forms  of  localized  cedema,  described 
under  the  term  giant  urticaria,  are  of  angioneurotic  origin.  The  acute 
cedema  associated  with  urticaria  and  gastro-intestinal  crises  which  occurs 
in  severe  purpura,  and  the  cases  of  cedematous  swelling  and  tumefaction  of 
the  whole  arm  upon  exertion,  are  to  be  referred  to  this  group.  The  local 
cedema  occurring  as  a  symptom  in  peripheral  multiple  neuritis  and  the 
cedema  of  beriberi  are  probably  of  nervous  origin,  as  is  hysterical  cedema. 


SYMPTOMS  AXD  SIGNS:    SKIN.  557 

(e)  (Edema  due  to  Other  Causes. — (Edema  neonatorum  is  a  rare  condi- 
tion sometimes  confused  with  sclerema,  from  which,  however,  it  is  patho- 
logically distinct.  It  is  encountered  in  feeble  infants,  especially  those  born 
prematurely  or  exposed  to  cold  after  birth.  Cases  of  hereditary  oedema 
have  been  described.  The  oedema  is  congenital  and  persistent;  it  involves 
one  or  both  legs  and  is  dense  and  inelastic.  It  shows  no  disposition  to 
increase  and  is  unattended  by  special  inconvenience. 

The  oedema  which  occurs  in  trichiniasis  is  of  diagnostic  importance. 
It  appears  in  the  face  and  over  the  affected  muscles,  and  undergoes  remark- 
able fluctuations  in  degree  during  the  course  of  the  disease. 

General  oedema  in  the  absence  of  nephritis  is  not  infrequently  observed 
in  certain  of  the  infectious  diseases,  as  scarlet  fever  and  diphtheria;  it  may 
follow  the  therapeutic  injection  of  the  different  sera  and  in  some  instances 
the  administration  of  potassium  iodide.  Slight  oedema  of  the  feet  and 
ankles — a  mere  puffiness — is  not  uncommon  in  individuals  otherwise 
health)',  after  prolonged  standing  or  walking  or  after  forced  marches. 

Lymphoedema. — The  transudation  of  lymph  through  the  walls  of  the 
lymphatic  vessels,  or  distention  of  the  lymph  spaces  from  mechanical 
obstruction,  may  cause  great  swelling,  which  is  usually  local  or  confined  to 
a  single  limb.  It  results  from  pressure  upon,  or  internal  occlusion  of,  a 
lymph-vessel  and  is  seen  in  the  lymph  scrotum  and  certain  forms  of  elephan- 
tiasis caused  by  the  Filaria  sanguinis  hominis  and  accompanied  by  chyluria. 
Lymphoedema  involving  a  member — macromelia — sometimes  occurs  in 
lymphadenoma.  This  form  differs  from  ordinary  oedema  by  its  greater 
firmness  and  brawniness — a  very  important  point  in  differential  diagnosis. 

It  is  of  diagnostic  importance  to  recognize  the  distinction  between 
the  various  forms  of  oedema  and  myxoedema — an  affection  of  the  thyroid 
gland  characterized  by  swelling  of  the  skin,  eyelids,  and  other  parts  of  the 
body,  due  to  the  deposition  in  the  skin  and  subcutaneous  tissues  of  a  mucin- 
ous material.  The  skin  is  dry,  rough,  and  swollen,  but  firm  and  inelastic, 
and  does  not  pit  on  pressure. 

Certain  connective-tissue  dystrophies  present  a  superficial  resemblance 
to  localized  oedema.  The  swellings  usually  involve  the  outer  or  posterior 
aspect  of  the  extremities,  but  may  appear  at  various  parts  of  the  trunk. 
They  arc  to  be  differentiated  from  oedema  by  their  localization,  the  absence 
of  piniiiLr  upon  pressure,  and  by  other  appearances  of  the  skin  characteristic 
of  oedema. 

Scleroderma,  a  brawny  induration  of  the  skin,  in  some  instances 
chronic  oedema.  Two  forms  are  recognized,  the  circumscribed 
and  the  diffuse  in  which  large  areas  are  involved.  The  skin  is  brawny, 
hard,  and  inelastic.  When  circumscribed  the  patches  are  irregularly  oval 
and  vary  in  diameter;  they  may  be  as  large  as  the  hand.  They  are  preceded 
by  hyperemia  of  the  skin.  The  disease  is  more  common  in  women  than  in 
men  aid  frequently  shows  itself  about  the  neck  and  breasts.  The  diffuse 
form  involves  the  extremities  and  face.  The  skin  is  hard  and  firm  with 
stiffness  and  tension,  it  is  adherent  to  the  underlying  tissues  and  cannot 
be  pinched  up  into  folds.  There  is  impairment  of  movement.  Very  often 
there  are  vasomotor  disturbances  with  cyanosis.  Pigment  alterations  are 
frequent-    both  melanoderma  and  leucoderma. 


558  MEDICAL  DIAGNOSIS. 

Sclerema  neonatorum  is  a  rare  disease  of  the  new-born  in  which  the 
skin  rapidly  assumes  the  clinical  appearance  of  scleroderma.  It  is  usually 
fatal.  It  presents  superficial  points  of  resemblance  to  oedema  neonatorum, 
from  which  it  is  to  be  distinguished  by  the  complete  absence  of  the 
ordinary  signs  of  anasarca. 

Scurvy  sclerosis — a  deep  brawny  infiltration  of  the  subcutaneous  tissues 
and  muscles,  with  hemorrhagic  discoloration  of  the  overlying  skin — fre- 
quently seen  on  the  calves  of  the  legs,  is  not  to  be  confounded  with  oedema, 
although  it  is  very  often  associated  with  it. 

Subcutaneous  Emphysema. — The  presence  of  gas,  usually  air,  in  the 
meshes  of  the  subcutaneous  tissue  gives  rise  to  swelling  and  puffiness  of 
the  surface  which  may  be  either  general  or  local.  The  appearance  is  not 
unlike  that  of  oedema,  but  upon  palpation  a  peculiar  crackling  is  to  be  felt 
and  heard,  due  to  the  displacement  of  bubbles  of  air  in  the  tissues.  The 
surface  resistance  is  lower  than  normal  and  pitting  from  pressure  does  not 
occur.  Upon  percussion  the  sound  is  tympanitic.  The  skin  is  pale  and  has 
a  distended  appearance.  In  very  rare  cases  subcutaneous  emphysema  is 
due  to  the  presence  of  aerogenous  bacteria — Bacillus  aerogenes  capsulatus — 
and  allied  organisms.  This  gaseous  and  necrotic  oedema  occurs  in  serious 
wound  infection  and  may  extensively  involve  the  subcutaneous  tissues  of 
the  body.  The  infection  may  proceed  from  the  uterus,  gastro-intestinal 
canal,  or  respiratory  tract.  Analogous  to  this  condition  is  the  subcutaneous 
emphysema  of  malignant  oedema.    It  is  sometimes  associated  with  tetanus. 

In  the  greater  number  of  cases  the  air  finds  its  way  under  the  skin 
through  an  external  wound  or  through  the  ulceration  or  laceration  of  some 
air-containing  organ.  Subcutaneous  emphysema  is,  therefore,  an  accident 
of  carcinomatous  or  other  ulceration  of  the  oesophagus,  of  diseases  attended 
by  violent  paroxysmal  cough  by  which  the  alveolar  tissue  is  mechanically 
torn,  or  occasionally  of  the  after-treatment  of  tracheotomy,  the  air  being 
forced  into  the  subcutaneous  tissues  by  efforts  of  cough.  The  air  usually 
accumulates  about  the  root  of  the  neck  and  over  the  manubrium.  It  may 
invade  the  tissues  underlying  the  skin  very  extensively  and  sometimes  in- 
volves the  greater  part  of  the  body.    As  a  rule  it  undergoes  rapid  resorption. 

Cutaneous  hemorrhages  appear  as  spots  or  streaks  of  varying  size, 
at  first  red,  but  quickly  becoming  darker.  Small  hemorrhages — petechia: — 
frequently  have  their  origin  in  the  hair  follicles.  Larger  hemorrhages — 
ecchymoses — are  diffuse.  Hemorrhages  arranged  in  the  skin  in  the  form 
of  lines  and  streaks  are  called  vibices.  The  term  suggil!atio?i  is  sometimes 
used  to  describe  the  ecchymosis  following  a  bruise.  Hcematoma  is  a  tumor 
containing  effused  blood.  Cutaneous  hemorrhages  may  occur  upon  any 
part  of  the  bod}*,  but  when  due  to  constitutional  disease  the}*  are  more 
abundant  upon  the  lower  extremities.  In  consequence  of  transformations 
in  the  haemoglobin  the  color  during  resorption  undergoes  progressive  changes 
to  blue,  green,  and  yellow,  and  gradually  fades.  The  appearance  and  dis- 
tribution of  petechia?  is  characteristic  of  cutaneous  hemorrhage.  They  are 
not  usually  elevated  above  the  skin.  Occasionally  in  purpura  there  are 
vesicular  points  distended  with  blood.  In  doubtful  cases  cutaneous  hem- 
orrhages may  be  distinguished  from  local  hyperemia  or  erythema  by  the 
fact  that  they  do  not  disappear  when  the  skin  is  made  tense  by  traction 


SYMPTOMS  AND  SIGNS:   SKIN.  559 

upon  it  of  the  thumb  and  finger  or  by  pressure  with  a  glass  slide.  In 
local  hyperemia  the  spot  of  redness  disappears;  in  hemorrhage,  owing  to 
the  expression  of  the  blood  from  the  surrounding  capillaries,  it  becomes 
more  distinct.  Affections  characterized  by  the  extravasation  of  blood  into 
the  skin  are  collectively  described  under  the  term  purpura. 

Cutaneous  hemorrhage  is  in  all  cases  of  diagnostic  importance.  The 
more  important  conditions  with  which  it  is  associated  are  traumatism, 
intense  venous  stasis,  the  severe  and  especially  the  malignant  infections, 
sepsis  of  various  kinds,  deep  jaundice,  and  cachectic  and  anaemic  states. 
It  is  a  characteristic  phenomenon  of  the  action  of  certain  snake  venoms 
and  under  exceptional  circumstances  follows  the  administration  of 
copaiba,  quinine,  ergot,  iodine,  and  other  drugs. 

Hemorrhage  into  the  skin  occasionally  occurs  in  acute  myelitis, 
severe  neuralgia,  and  in  tabes.  In  the  last  it  is  very  often  transient.  The 
bleeding  points  or  stigmata  that  have  attracted  so  much  attention  in  rare 
cases  of  hysteria  are  of  nervous  origin. 

It  is  frequently  associated  with  arthritis.  The  relationship  of  these 
conditions  has  been  regarded  without  adequate  reason  as  rheumatic. 

Other  changes  in  the  skin  of  diagnostic  importance  are:  striations, 
desquamation,  furunculosis,  cicatrices,  and  glossy  skin. 

Striations. — The  striae  of  the  skin  of  the  abdomen  and  those  occur- 
ring in  oedema  and  peritoneal  effusion,  which  resemble  the  striations  of 
pregnancy,  have  already  been  described.  They  frequently  disappear  after 
resorption  of  the  fluid,  but  may  persist  for  a  long  time.  Similar  striations 
may  attend  the  rapid  development  and  equally  rapid  resorption  of  a 
thick  panniculus  adiposus.  They  are  encountered  in  cases  of  great  abdomi- 
nal distention  from  rapidly  developing  tumors  or  other  cause. 

Desquamation. — Shedding  of  the  epidermis  is  of  diagnostic  impor- 
tance. A  diffuse  desquamation  of  the  trunk  and  extremities,  usually  in  the 
form  of  fine  scales,  occurs  in  the  cachexia  associated  with  emaciation.  A 
similar  fine-scaled  desquamation  follows  measles.  A  coarser  desquamation, 
sometimes  lamellar,  is  almost  constant  after  scarlet  fever.  A  coarse  des- 
quamation follows  erysipelas.  The  decrustation  of  the  variolous  diseases 
may  be  mentioned  in  this  connection. 

Furunculosis.— Boils  or  furuncles  are  the  expression  of  an  acute 
inflammation  of  a  hair  follicle  and  its  sebaceous  gland  and  the  connective 
tissue  immediately  surrounding  them.  It  is  a  local  process  due  to  an  infec- 
tion through  the  follicle  by  pus-producing  organisms,  usually  the  Staphy- 
lococcus aureus.  Furunculosis  occurs  in  conditions  of  lowered  vitality, 
as  during  the  convalescence  from  infectious  diseases,  especially  enteric 
fever.  The  occurrence  of  furuncles  in  crops,  or  their  persistent  recurrence, 
is  a  common  event  in  diabetes  mcllitus  and  should  always  lead  to  an 
examination  of  the  urine  for  the  presence  of  sugar. 

CICATRICES  or  Scars. — These,  whether  recent  or  old,  constitute 
important  diagnostic  signs.  In  doubtful  cases  special  significance  attaches 
to  the  presence  or  absence  of  the  scars  of  vaccination  and  their  characters 
and  to  the  scars  of  smallpox.  The  scars  of  furuncles  and  carbuncles,  of 
lupus,  of  inguinal  buboes,  and  those  left  by  tuberculous  glands  which  have 
healed   spontaneously  or  been   removed   are  very  suggestive  in   doubtful 


560 


MEDICAL  DIAGNOSIS. 


cases.  The  scars  left  by  tuberculous  disease  of  the  glands  or  bones  are 
usually  retracted  and  adherent.  The  presence  or  absence  of  scars  upon  the 
genitalia  following  the  primary  syphilitic  infection  is  of  great  importance. 
They  are  usually  difficult  to  discover  in  the  female  and  are  not  always 
persistent.  The  serpiginous  cicatrices  of  late  syphilis  cannot  be  mistaken. 
Cicatrices  produced  by  therapeutic  measures,  such  as  cupping,  venesection, 

leeching,  the  application  of  croton  oil  and 
tartar  emetic  ointment,  and  those  left  by 
surgical  operations  are  of  importance  in 
the  anamnesis.  Occasionally  scars  upon 
the  head  or  elsewhere  constitute  sugges- 
tive diagnostic  evidence  in  obscure  nervous 
diseases.  Scars  upon  the  tongue,  the  result 
of  laceration  during  the  epileptic  par- 
oxj^sm,  may  serve  to  clear  up  any  doubt 
as  to  the  character  of  convulsive  seizures. 
Glossy  Skin.  —  The  appearance  is 
characteristic.  The  skin  is  atrophied  and 
attached  to  the  subjacent  structures.  It  is 
smooth,  tense,  and  hairless  and  occurs  most 
frequently  and  is  more  pronounced  in  the 
hands  and  fingers.  It  may  develop  else- 
where. The  condition  is  the  result  of  the 
trophic  disturbance  caused  by  traumatic  or 
other  lesions  of  the  nerves.  It  is  encoun- 
tered in  extremities  that  have  been  splinted 
after  fracture,  forms  of  neuritis,  in  condi- 
tions giving  rise  to  the  claw  hand,  in  long- 
standing oedema,  and  in  some  advanced 
cases  of  arthritis  deformans.  It  is  not 
often  seen  in  young  persons. 

Collateral   Circulation    in    the    Skin. 
- — Dilatation  of  the  superficial  vessels  fre- 
quently sheds  light  on  symptoms  dependent 
upon  deeper  circulatory  derangements.    In 
aged  persons  the  overfilled  veins  of  the  ex- 
tremities, showing  prominently  through  the 
translucent  atrophic  skin,  are  an  indication 
of  the  diminished  cardiac  power  associated 
with   general  involution   of   the    muscular 
system.     The  veins  are  darker  in  color  than  the  blood  which  they  contain 
— a  phenomenon  doubtless  due  to  intensification  of  the  color  in  transmission 
through  the  skin. 

In  tumors  of  the  mediastinum  which  compress  the  great  veins  of  the 
thorax,  especially  the  vense  cava?  superior  and  inferior,  the  venous  collat- 
erals upon  the  anterior  surface  of  the  chest  may  be  greatly  enlarged.  The 
blood  is  transferred  from  the  compressed  vena  cava  inferior  by  way  of  the 
intercostal  veins  and  the  internal  mammary  vein  to  the  superior  vena  cava, 
or  the  reverse. 


Fig.  204. —  Distended  veins  of  the  leg 
and  abdomen  in  a  case  of  mediastinal 
tumor. — Jefferson  Hospital. 


SYMPTOMS  AND  SIGNS:    SKIN. 


561 


Thrombosis  of  the  vena  cava  ascendens  or  of  both  common  iliac  veins 
results  in  the  development  upon  the  surface  of  the  abdomen  and  antero- 
lateral aspects  of  the  chest  of  prominent  sinuous  venous  enlargements, 
sometimes  reaching  the  thickness  of  a  finger,  by  which  the  blood  from  the 
lower  extremities  and  the  kidneys  is  conveyed  to  the  veins  of  the  thorax. 
In  cirrhosis  of  the  liver  and  portal  thrombosis  the  compensatory  circula- 
tion is  often  by  way  of  the  superficial  veins.  Occasionally  a  greatly  enlarged 
para-umbilical  vein  passes  from  the  hilus  of  the  liver  along  the  course 
of  the  round  ligament  and  joins  the 
epigastric  veins  at  the  navel,  produc- 
ing a  large  varix  with  wavy  radial 
distribution  of  the  veins  known  as 
the  caput  Medusce.  More  commonly 
branches  pass  in  the  round  and  sus- 
pensory ligaments  and  unite  with  the 
epigastric  and  mammary  systems. 
The  vessels  are  numerous  and  of  no 
great  size.  An  important  point  of 
difference  between  the  enlargement 
of  the  superficial  collateral  veins  in 
obstruction  of  the  vena  cava  and 
portal  obstruction  is  to  be  found  in 
their  distribution.  In  the  former  the 
enlarged  collaterals  usually  occupy 
the  anterolateral  aspect  of  the  chest: 
in  the  latter  the  region  around  the 
navel  and  ensiform  cartilage.  It  is 
important  to  determine  in  which 
direction  the  blood  in  the  distended 
vein  flows.  This  is  done  by  empty- 
ing the  vein  by  stroking  it  between 
two  fingers  and  determining  by  re- 
moval of  the  pressure  of  the  fingers 
alternately  from  which  direction  the 
blood  stream  comes.  In  great  disten- 
tion of  the  veins  the  valves  become 
inadequate  and  this  investigation  is 
without  result.     The  small  vascular 

dendrites  so  often  seen  in  irregular  arrangement  at  the  base  of  the  thorax  in 
chronic  affections  of  the  lungs  and  pleura  indicate  local  areas  in  which  col- 
lateral circulation  has  been  established  between  the  lungs  and  skin.  They 
are  especially  common  in  pleural  adhesions  and  are  frequently  seen  upon 
the  upper  part  of  the  back  in  chronic  pulmonary  tuberculosis  with  greal 
pleural  thickening.  In  many  cases  those  minute  dendritic  enlargements  at 
the  base  of  the  chest  and  the  borders  of  the  area  of  superficial  cardiac  dul- 
ness  are  without  pathological  significance,  since  they  occur  in  healthy  indi- 
viduals. They  have  a  certain  clinical  interest,  however,  since  by  their 
distribution  they  indicate  upon  inspection  tin-  position  of  the  borders  of  the 
lung.    Knlargement  of  the  veins  of  the  legs  mav  be  due  to  changes  in  their 

36 


Fi<;.  20.5^4. — Varicose  veins. — German  Hospital. 


562  MEDICAL  DIAGNOSIS. 

walls  on  the  one  hand  or  to  thrombosis  or  pressure  on  the  other.  Enlarge- 
ment of  the  veins  of  both  legs  is  caused  by  the  obstruction  of  the  vena  cava 
or  both  iliacs.  Great  enlargement  of  the  veins  of  the  legs,  with  the  formation 
of  varices,  sometimes  occurs  after  repeated  pregnancies,  and  enormous  vari- 
cosity of  one  leg,  with  great  dilatation,  frequently  results  from  venous 
thrombosis  following  pregnancy  or  the  infectious  diseases,  especially  enteric 
fever.  The  varicosities  which  occur  in  the  absence  of  pressure  or  throm- 
bosis are  largely  due  to  changes  in  the  walls  of  the  veins  themselves. 

THE   NAILS. 

The  appearance  of  the  nails  is  to  some  extent  indicative  of  the  state 
of  nutrition  and  habits.  The  deformity  arising  from  biting  the  nails  is 
characteristic  and  consists  in  shortening  of  the  nail  with  projection  of  the 
tip  of  the  finger,  into  which  the  edge  of  the  nail  tends  to  bury  itself.  Coarse 
longitudinal  stria?  associated  with  brittleness  are  said  to  indicate  gouty 
tendencies.  Small  white  flecks — leucopathia  unguis — are  the  result  of 
trifling  knocks;  the  color  is  due  to  the  presence  of  air  among  the  cells. 
Transverse  arched  bands,  dull  and  opaque,  contrasting  with  the  normal 
glistening  surface,  are  seen  after  severe  acute  illness  and  indicate  a  period 
of  malnutrition.  They  appear  at  the  root  of  the  nail  and  gradually  advance. 
They  are  often  seen  after  enteric  fever  and  sometimes,  in  the  case  of  relapse, 
there  is  a  corresponding  secondary  band.  Pressure  upon  the  nails  drives 
blood  from  the  capillaries  of  the  bed.  The  blanching  is  marked  and  some- 
what prolonged  in  anaemic  states.  The  nail  is  normally  of  a  pink  tint. 
Cyanosis  shows  itself  early  in  the  nails  and  their  blueness  is  a  measure  of 
its  intensity.  When  the  capillary  pulse  is  present  it  may  be  seen  in  the 
nail-beds,  especially  after  slight  pressure.  The  nutrition  of  the  nails  is 
affected  in  various  skin  diseases.  They  become  dry,  fragile,  and  malformed 
in  neuritis,  syringomyelia,  Raynaud's  disease,  and  scleroderma.  Destruc- 
tion of  the  nails  occurs  in  the  neuritis  of  Morvan's  disease  and  leprosy. 
In  hemiplegia  and  infantile  palsy  the  growth  of  the  nails  upon  the  paralyzed 
side  is  retarded.  Onychia  is  ulceration  of  the  nail  matrix.  It  may  be  due 
to  syphilis  or  tuberculosis.  In  chronic  disease  of  the  chest  the  nails  become 
hypertrophied  and  incurvated  and  the  terminal  phalanges  clubbed — the 
Hippocratic  fingers.  These  changes  are  seen  most  frequently  in  bronchi- 
ectasis and  empyema,  less  often  in  phthisis.  The  deformity  may  develop 
very  rapidly.  Trifling  lesions  at  the  root  of  the  nail — a  mere  splitting  of 
the  fold  of  epidermis  at  the  side  of  the  finger-nail,  may  be  the  point  of 
serious  infection.  Malignant  endocarditis  and  tetanus  have  arisen  from 
this  cause,  and  such  sores  upon  the  finger  of  the  surgeon  are  frequently 
the  seat  of  the  initial  lesion  of  syphilis.  Congenital  absence  and  deformities 
of  the  nails  are  not  common.  They  may  be  hereditary  and  are  usually 
associated  with  defects  in  development  of  the  hair  and  teeth. 

Shedding  of  the  nails  sometimes  occurs  in  syphilis,  alopecia  areata, 
saccharine  diabetes,  hysteria,  and  other  neurotic  conditions.  Extravasa- 
tion of  the  blood  beneath  the  nails  may  occur  from  injury  or  very  rarely 
in  purpuric  affections.  The  blood-clot  brings  about  a  separation  of  the 
nail  from  its  bed  and  its  ultimate  detachment. 


SYMPTOMS  AND  SIGNS:    HAIR.  563 

THE   HAIR. 

Wide  variations  in  color,  texture,  and  abundance  occur  in  different 
individuals.     Certain  changes  are  of  diagnostic  importance. 

Color. — Grayness  or  canities  may  begin  early  in  life.  It  is  a  sign  of 
old  age  but  there  are  people  who  grow  old  without  growing  gray.  Gray 
hair  in  young  people  is  sometimes  hereditary.  It  is  often  associated  with 
early  arteriocapillary  sclerosis.  In  a  family  in  which  nearly  every  member 
for  three  generations  was  the  victim  of  chronic  nephritis  it  was  characteristic 
for  the  hair  to  turn  gray  before  thirty.  Early  grayness,  however,  is  not 
incompatible  with  excellent  health.  In  rare  instances  rapid  whitening  of 
the  hair  has  been  attributed  to  extreme  terror  or  anxiety.  Circumscribed 
patches  of  gray  hair  are  occasionally  seen  in  healthy  individuals.  Their 
development  sometimes  appears  to  depend  upon  severe  neuralgia  involv- 
ing the  distribution  of  the  supra-orbital  branch  of  the  fifth  nerve.  It  is 
easy  for  the  close  observer  to  detect  bleached  or  dyed  hair.  To  the  physician 
the  former  is  suggestive  of  an  undisciplined  life,  the  latter  of  chronic  lead 
poisoning  as  the  cause  of  nervous  symptoms  otherwise  obscure.  Discolor- 
ation of  the  hair  occurs  in  workers  in  copper,  cobalt,  indigo,  and  from  local 
contact  with  dyes.  Change  in  color  may  occur  after  severe  illness  with 
temporal-)'  loss  of  hair'  or  after  frequently  repeated  excessive  sweating 
such  as  follows  the  hypodermic  use  of  pilocarpine. 

Hypertrichosis. — A  growth  of  hair  that  is  abnormal  in  quantity  or  in  loca- 
tion may  be  congenital  or  acquired.  It  is  a  deformity  rather  than  a  disease. 
Very  rare  instances  have  been  reported  in  which  a  growth  of  hair  has  covered 
the  entire  body  except  the  palms,  soles,  terminal  phalanges,  upper  eyelids, 
borders  of  the  lips,  prepuce,  and  glans  penis.  Hirsuties  is  more  commonly 
localized.  The  causes  of  this  condition  are  obscure.  Among  them  heredity 
and  irregularities  or  arrest  of  the  sexual  functions  are  prominent.  A  luxuri- 
ant growth  of  deeply  pigmented  hair  has  been  observed  in  Addison's  disease. 

Atrophy  of  the  hair  occurs  as  the  result  of  systemic  conditions  inter- 
fering with  nutrition.  The  hair  becomes  dry  and  lustreless  and  splits  at 
the  end.  It  may  undergo  atrophy  in  local  diseases  of  the  scalp  and  in 
general  conditions,  as  extreme  emaciation  and  cachexia.  Imperfect  nutri- 
tion of  the  hair  is  conspicuous  in  myxcedema  and  occurs  in  advanced  cases 
of  pulmonary  consumption. 

Alopecia  may  involve  the  scalp  or  other  hairy  parts  of  the  body.  It  may 
be  congenital  and  is  usually  accompanied  by  defects  in  the  teeth  and  nails. 
This  form  is  very  often  hereditary.  The  hair  does  not  usually  grow  in  scars 
upon  the  scalp.  Alopecia  senilis  accompanies  other  senile  changes.  Prema- 
ture falling  of  the  hair  sometimes  appears  to  be  an  idiopathic  condition.  It 
occurs  in  various  local  and  systemic  diseases.  Among  the  latter  are  acute 
febrile  infections,  syphilis,  and  erysipelas.     As  a  rule  the  hail  grows  again. 

Alopecia  areata  or  circumscribed  patches  of  baldness  appears  in  some 
instances  to  be  a  trophoneurosis  occurring  after  shock  or  injury  to  the 
nervous  system.      In  others  it  appears  to  be  a  local  parasitic  disease. 

Diseases  of  the  skin  as  such  do  not  fall  within  the  scope  of  this  work. 
The  cutaneous  manifestation-  of  the  individual  constitutional  and  organic 
diseases  are  considered  elsewhere  (see  Tart  IV,  Vol.  II). 


564  MEDICAL  DIAGNOSIS. 


XII. 

GENITO-URINARY  SYSTEM;    MICTURITION;    THE    REPRODUC- 
TIVE ORGANS. 

The  diagnostic  significance  of  the  results  of  examination  of  the  urine 
by  laboratory  methods  is  set  forth  in  a  previous  chapter.  The  clinical 
facts  may  properly  be  considered  separately. 

MICTURITION— URINATION. 

The  urine  is  secreted  continuously  and  conveyed  by  the  ureters  to  the 
bladder,  from  which  it  is  ejected  at  intervals  through  the  urethra  by  the 
act  of  micturition.  The  urine  accumulating  in  the  bladder  is  prevented 
from  escaping  by  the  elasticity  of  the  parts  surrounding  the  internal  ure- 
thral orifice  and  the  contraction  of  the  internal  sphincter.  When  the 
accumulation  reaches  a  certain  point  the  desire  to  pass  water  is  aroused. 
The  external  sphincter  may  be  controlled  by  voluntary  effort.  The  act  of 
micturition  consists  in  strong  contraction  of  the  bladder  with  the  simul- 
taneous relaxation  of  the  sphincters  and  the  contraction  of  the  abdominal 
muscles,  especially  toward  the  close  of  the  act.  The  contraction  of  these 
muscles  with  closure  of  the  glottis  and  fixation  of  the  diaphragm  increases 
the  pressure  upon  the  contents  of  the  abdominal  and  pelvic  cavities  and 
favors  the  complete  emptying  of  the  bladder.  The  peculiar  sensation 
caused  by  the  accumulation  of  urine  in  the  bladder  is  followed  by  the 
reflex  muscular  contractions  which  constitute,  the  act  of  micturition. 
Not  only  is  this  act  largely  under  the  control  of  the  will,  but  the  ability  to 
void  small  quantities  is  also  to  some  extent  voluntary. 

The  average  total  daily  quantity  of  urine  in  healthy  men  is  1200  to 
1700  c.c;  in  women  the  amount  is  less  by  200-300  c.c.  This  represents 
the  water  excreted  by  the  kidneys,  but  there  is  in  health  as  well  as  in  disease 
a  vicarious  relationship  between  the  function  of  those  organs  and  the  skin 
and  lungs,  so  that  during  increased  cutaneous  and  respiratory  activity,  as 
in  prolonged  exercise  or  in  warm  weather,  the  quantity  of  urine  may  be 
reduced  to  400-500  c.c.  in  twenty-four  hours. 

The  quantity  is  diminished  in  disease  in  a  corresponding  manner. 
Thus,  the  loss  of  fluid  by  pathological  sweating,  profuse  vomiting,  colliqua- 
tive diarrhoea,  and  hemorrhage  is  attended  by  more  or  less  marked  reduc- 
tion in  the  urine.  The  quantity  is  also  reduced  in  acute  nephritis,  in 
lowering  of  the  blood-pressure  from  any  cause,  in  many  febrile  conditions, 
and  in  dropsies  and  effusions  into  the  serous  sacs.  Suppression  of  urine 
more  or  less  complete  is  designated  anuria — to  a  less  extent  oliguria. 

An  abnormal  and  continued  increase  of  the  daily  quantity  of  urine, 
not  accounted  for  by  increased  ingestion  of  fluid,  constitutes  the  patho- 
logical condition  designated  polyuria.  This  condition  occurs  in  diabetes 
insipidus  and  mellitus,  in  emotional  states,  in  hysteria,  during  the  epileptic 
paroxysm,  in  irritable  lesions  of  the  floor  of  the  fourth  ventricle,  under  the 


SYMPTOMS  AND  SIGNS:   MICTURITION.  565 

influence  of  diuretics,  in  contracted  kidneys,  in  chronic  parenchymatous 
nephritis,  in  lardaceous  renal  disease,  from  increased  blood-pressure,  and 
as  a  result  of  the  resorption  of  transudates  and  exudates. 

The  daily  quantity  is  voided  in  several  acts  of  micturition,  usually 
about  five,  but  the  number  within  normal  limits  is  largely  determined  by 
the  habits  and  circumstances  of  the  individual. 

The  following  abnormal  conditions  are  of  diagnostic  importance: 
(a)   Dysuria. — This  term  is  comprehensively  employed  to  designate 
difficult,  slow,  and  frequent  micturition,  and,  since  these  symptoms  are 
mostly  though  not  always  attended  with  distress  which  is  often  urgent, 
it  includes  painful  micturition. 

1.  Vesical  tenesmus  constitutes  the  most  severe  form  of  dysuria. 
It  consists  of  painful  spasm  of  the  bladder  and  is  often  associated  with 
rectal  tenesmus.  The  spasm  is  often  so  urgent  that  the  patient  is  unable 
to  remain  at  rest,  but  returns  at  short  intervals  to  the  ineffectual  and 
agonizing  attempt  to  pass  water,  with  the  result  that  a  few  drops  at  most 
are  voided  with  violent  bearing  down  and  burning  pain  in  the  urethra. 

2.  Strangury. — Not  rarely  a  few  drops  of  blood  or  bloody  mucus  are 
discharged  in  the  spasmodic  efforts  at  urination,  and  the  condition  is  de- 
scribed as  strangury.  This  term  is,  however,  frequently  employed  inter- 
changeably with  tenesmus. 

Very  concentrated  and  acid  urine  is  a  cause  of  dysuria  and  the  ingestion 
of  certain  condiments  in  excess,  as  mustard,  pepper,  and  horseradish,  may 
produce  similar  inconvenience.  The  absorption  of  cantharides  and  turpen- 
tine applied  to  the  surface,  or  overdoses  of  these  substances,  may  be 
followed  by  strangury.  A  sudden  attack  of  vesical  tenesmus  for  which  no 
obvious  cause  is  discoverable  may  be  found  upon  investigation  of  the 
facts  of  the  case  to  be  a  tabetic  crisis. 

Dysuria,  especially  these  more  intense  forms,  is  liable  to  occur  in  al- 
most all  acute  inflammatory  diseases  of  the  urinary  tract.  They  are 
encountered  therefore  in  posterior  gonorrhoea  and  in  gonorrhceal  inflam- 
mation of  the  neck  of  the  bladder,  and  in  acute  cystitis,  prostatitis,  and  pye- 
litis. Dysuria  also  accompanies  the  chronic  forms  of  these  affections  but 
is  much  less  urgent  and  distressing.  Tenesmus  is  also  symptomatic  of 
direct  irritation  of  the  bladder,  as  by  stone,  gravel,  foreign  bodies,  parasites, 
and  local  ulceration.  Reflex  dysuria  with  tenesmus  is  sometimes  present 
in  renal  colic. 

Dysuria  is  a  symptom  of  incomplete  retention.  When  after  the  act 
of  micturition  there  is  residual  urine,  it  is  evident  that  the  capacity  of  the 
organ  will  be  more  speedily  reached  than  when  it  is  emptied  normally. 
Urination  becomes  more  frequent  and  more  difficult.  This  form  of  dysuria 
occurs  in  paresis  of  the  bladder,  as  in  tabes,  hypertrophied  prostate,  tumor 
involving  the  neck  of  the  bladder,  stricture  and  phimosis,  prostatic  abscess, 
arteriosclerosis  of  the  vesical  arteries,  spasm  of  the  neck  of  the  bladder, 
and  oedematous  swelling  of  the  urethra]  mucosa  in  acute  gonorrhoea.  A 
chancre  of  the  urethra  may  art  in  the  same  way,  and  in  the  variolous  dis- 
eases pocks  in  the  meatus  may  occasion  similar  symptoms. 

Dysuria  frequently  attends  general  peritonitis,  acute  inflammatory 
diseases  of  the  pelvic  organs,  and  may  occur  in  dysmenorrhea. 


566  MEDICAL  DIAGNOSIS. 

(b)  Frequent  Micturition. — This  occurs  in  polyuria.  It  is  obvious 
that  in  the  absence  of  dilatation  of  the  bladder  an  increase  in  the  quantity 
of  urine  must  be  followed  by  an  increase  in  the  frequency  with  which  it  is 
voided.  Hence  in  diabetes  insipidus  and  diabetes  mellitus,  in  contracted 
kidneys  and  in  some  forms  of  pyelitis  the  frequency  of  urination  is  greatly 
increased.  A  diabetic  who  voids  6  litres  of  urine  in  twenty-four  hours, 
with  an  average  vesical  capacity  of  about  300  c.c,  would  be  obliged  to  pass 
water  at  least  twenty  times  in  the  course  of  the  day — a  requirement  which 
is  slightly  diminished  by  a  gradual  increase  in  the  size  of  the  bladder.  When, 
on  the  other  hand,  the  bladder  has  undergone  concentric  hypertrophy  in 
consequence  of  chronic  cystitis  and  its  capacity  is  greatly  diminished,  the 
necessity  to  void  urine  at  short  intervals  becomes  imperative.  If  the  call 
be  not  obeyed,  as  in  deep  sleep,  the  urine  may  be  involuntarily  discharged. 

Frequent  micturition  is  often  due  to  psychical  causes,  among  them 
fright  and  excitement.  Soldiers  in  battle  and  students  awaiting  examina- 
tion constitute  oft-quoted  examples.  The  urine  is  voided  at  short  intervals 
and  in  small  amounts  and  often  involuntarily.  It  is  also  a  common  symp- 
tom in  hysteria  and  neurasthenia. 

(c)  Slow  Micturition. — The  act  is  slow,  prolonged,  and  difficult  in  all 
conditions  characterized  by  mechanical  obstruction  to  the  outflow  and  in 
nervous  affections  attended  by  paresis  of  the  vesical  wall.  Hence  the  form 
of  dysuria  encountered  in  incomplete  urinary  retention  from  any  cause  is 
characterized  by  slow  or  prolonged  micturition.  Stillicidium  urince  or  the 
slow  discharge  of  urine  drop  by  drop  has  been  described  under  the  term 
"incontinence  of  retention."  It  occurs  in  the  low  fevers  and  in  soporose 
and  comatose  conditions,  when,  because  of  the  neglect  of  a  routine  physical 
examination  and  of  the  use  of  the  catheter,  the  bladder  has  been  allowed 
to  become  overdistended. 

(d)  Incontinence  of  Urine. — This  condition  is  due  to  mechanical  and 
nervous  causes. 

1.  Mechanical  causes  are  chiefly  operative  in  women.  Laceration  of 
the  perineum  or  injuries  to  the  urethra  sustained  in  parturition,  relaxation  of 
the  floor  of  the  pelvis,  and  cystocele  are  common  causes  of  urinary  inconti- 
nence. The  urine  may  dribble  constantly  or  be  discharged  in  gushes  upon 
any  muscular  effort  which  increases  the  pelvic  pressure,  as  lifting,  stooping, 
or  coughing.  Violent  sudden  cough,  as  in  pertussis,  may  cause  incontinence 
in  depressed  or  asthenic  conditions  with  relaxation  of  the  sphincter  muscles. 

2.  The  nervous  causes  of  incontinence  are  much  more  common. 
They  may  be  cerebral,  as  in  coma  and  shock,  idiocy  and  dementia,  or  the 
stuporous  states  of  the  profound  infections;  spinal,  as  in  traumatism, 
hemorrhage,  and  tumors  of  the  cord,  transverse  myelitis,  meningitis,  and 
tabes;  or  reflex  in  consequence  of  the  local  irritation  of  ascarides,  phimosis, 
contracted  urinary  meatus,  stone  in  the  bladder,  cystitis,  or  highly  con- 
centrated or  acid  urine.  To  the  last  of  these  causes  may  be  referred  enuresis 
nocturna,  which  occurs  in  neurotic  children  and  acquires  the  force  of  a 
morbid  habit,  the  urine  being  voided  involuntarily,  as  a  rule  during  sleep, 
but  frequently  during  the  waking  hours  under  excitement  or  preoccupation. 
If  the  vesical  centre  in  the  lumbar  cord  is  destroyed,  complete  paralysis 
will  ensue,  with  retention  or  the  dribbling  incontinence  of  retention. 


SYMPTOMS  AXD  SIGNS:   MICTURITION.  567 

(e)  Retention  of  Urine.— Retention  and  incontinence  are  very  con- 
stantly associated,  and  are  due  in  man3r  instances  to  the  same  causes. 
Thus,  retention  may  occur  in  coma  from  any  cause,  in  the  soporose  states 
incident  to  profound  toxaemia,  as  in  the  graver  forms  of  the  infectious 
diseases  and  especially  in  the  terminal  infections,  in  peritonitis,  in  acute 
pelvic  inflammations,  and  in  injuries  and  diseases  of  the  spinal  cord. 

Temporary  loss  of  vesical  power  sometimes  results  from  overdisten- 
tion  in  consequence  of  prolonged  voluntary  retention.  Mechanical  causes 
of  retention  are  stricture,  urethritis,  the  arrest  of  a  calculus  in  the  urethra, 
prostatic  enlargement,  and  the  pressure  of  the  head  in  parturition.  Remark- 
able retention  of  urine  is  sometimes  observed  in  hysterical  persons. 

In  infants  this  condition  may  occur  from  phimosis,  inflammation  of 
the  prepuce,  or  highly  concentrated  or  acid  urine.  These  causes  may  act 
reflexly,  by  producing  spasm  of  the  sphincters,  or  mechanically.  The  pas- 
sage of  a  renal  calculus  through  the  ureter  may,  by  reflex  irritation,  give 
rise  to  frequent  micturition  on  the  one  hand  or  to  spasm  of  the  sphincters 
and  retention  on  the  other. 

(f)  Suppression  of  Urine — Anuria. — This  condition  may  be  mechani- 
cal, renal  or  general,  partial  or  complete. 

1.  Mechanical  causes  of  complete  anuria  are  renal  calculi  blocking 
both  ureters  simultaneously  or  the  ureter  when  only  one  exists.  The  symp- 
toms are  those  of  ura?mia.  The  condition  is  extremely  rare.  Life  may 
be  prolonged  several  days  with  complete  anuria;  in  Polk's  case  in  which 
a  solitary  kidney  was  removed,  the  patient  lived  eleven  days.  Partial 
anuria — oliguria — may  be  caused  by  the  presence  of  an  abdominal  aneurism 
or  tumor  upon  one  or  both  ureters,  or  by  a  kink  in  the  ureter  in  the  case 
of  an  ectopic  kidney,  or  by  malignant  disease  of  the  wall  of  the  bladder 
involving  one  or  both  urethral  orifices.  In  any  of  these  conditions  hydrone- 
phrosis may  occur. 

2.  Renal  lesions  leading  to  suppression  of  urine  are  acute  congestion, 
acute  nephritis;  the  acute  exacerbations  of  chronic  nephritis,  pyelitis, 
abscess  of  the  kidney,  perinephric  abscess,  and  hydro-  and  pyonephrosis. 
Among  the  rare  causes  of  suppression  is  thrombosis  of  the  inferior  vena 
cava  or  of  the  renal  vein. 

3.  General  conditions  accompanied  by  suppression  of  urine  are  extreme 
lowering  of  the  blood-pressure  such  as  occurs  in  profuse  hemorrhage  from 
any  cause;  collapse  or  shock  from  injuries,  surgical  operations;  the  per- 
foration of  hollow  viscera,  as  in  peptic  ulcer,  empyema  of  the  gall-bladder, 
enteric  fever,  or  rupture  of  the  uterus;  the  stage  of  collapse  in  cholera 
Asiatica,  cholera  nostras,  or  yellow  fever,  the  pernicious  malarial  fevers, 
and  acute  peritonitis.  Operations  upon  the  urinary  tract — even  so  trifling 
a  procedure  as  catheterization — may  in  elderly  men  be  followed  by  urinary 
suppression. 

This  symptom  also  occurs  in  acute  poisoning  by  phosphorus,  lead,  and 
turpentine,  in  acute  yellow  atrophy  of  the  liver,  and  in  sunstroke. 

Anuria,  more  or  less  complete,  and  prolonged  for  days,  is  occasionally 
observed  in  hysterical  girls.  In  rare  cases  there  are  symptoms  of  uraemia, 
but  as  a  rule  there  are  no  associated  symptoms  other  than  those  due  to 
the  hysteria.      In  such  cases,  in  order  to  avoid  deception,  the  patient   must 


568  MEDICAL  DIAGNOSIS. 

be  isolated  and  carefully  and  continuously  watched,  and  the  catheter  used 
at  unexpected  and  irregular  periods.  Anuria  may  result  from  reflex  irri- 
tation and  functional  arrest  in  a  normal  kidney,  the  ureter  of  the  opposite 
side  being  blocked  by  a  calculus,  or  the  opposite  kidney  having  been 
removed  by  operation. 

Haematuria. — When  small  amounts  of  blood  are  present  the  color  of 
the  urine  is  smoky.  With  larger  quantities  it  is  bright  red  or  even  dark 
brown  and  opaque  like  porter.  Erythrocytes  are  present,  usually  crenated 
or  as  rounded  shadowy  disks.  The  haemoglobin  is  soon  dissolved,  especially 
in  ammoniacal  urines  and  those  of  low  specific  gravity.  Blood  from  the 
kidneys  is  intimately  mixed  with  the  urine,  which  is  discolored  both  at 
the  beginning  and  at  the  end  of  the  act  of  micturition.  Clots  are  often 
present  and  they  may  be  in  the  form  of  casts  of  the  pelvis  or  ureters.  Blood 
from  the  bladder  may  not  appear  until  toward  the  end  of  micturition  or  at 
its  close.  Upon  washing  out  the  bladder  the  water  returns  tinged  if  the 
source  of  the  hemorrhage  be  in  the  bladder  but  clear  if  it  be  in  the  kidneys. 
The  differential  diagnosis  of  the  source  of  the  bleeding,  however,  is  often 
attended  with  difficulty  and  can  be  made  only  by  means  of  the  cystoscope 
or  a  differentiator  by  which  the  urine  from  each  ureter  may  be  obtained 
separately. 

Hematuria  may  be  symptomatic  of  the  following  conditions: 

1.  The  hemorrhagic  varieties  of  the  acute  febrile  infections,  forms 
of  purpura,  haemophilia,  very  severe  cases  of  scurvy,  and  leukaemia.  A 
special  form  of  haematuria  or  haemoglobinuria — black  water  fever — prevails 
in  certain  malarious  districts. 

2.  Diseases  of  the  Urinary  Passages. — Sarcoma  or  tuberculosis 
of  the  kidney,  calculus  in  the  ureter,  tumor,  ulceration  or  calculus  in  the 
bladder,  parasites  of  the  bladder — Bilharzia  haematobia,  psorospermiasis — 
or  rupture  of  veins  in  its  wall  may  be  the  cause  of  haematuria.  In  rare 
instances  this  condition  is  due  to  disease  of  the  prostate.  The  arrest  of  a 
calculus  in  the  urethra  or  acute  gonorrhceal  urethritis  is  sometimes  attended 
by  the  passing  of  blood.  This  symptom  occurs  in  strangury  and  there  are 
cases  of  persistent  haematuria  in  which  no  adequate  lesion  has  been  found. 

3.  Traumatism. —  Haematuria  follows  operations  upon  the  kidney. 
Gun-shot  wounds  or  stabs  'involving  the  kidney,  laceration  of  the  organ 
from  blows  upon  the  back,  falls  or  crushing  accidents  cause  profuse  bleed- 
ing. Similar  injuries  involving  the  bladder  or  prostate,  falls  or  kicks 
resulting  in  severe  contusion  of  the  perineum  and  laceration  of  the  urethra 
are  also  followed  by  hemorrhage,  and  this  symptom  frequently  follows 
the  use  of  the  catheter. 

(g)  Haemoglobinuria. — The  urine  is  discolored  by  haemoglobin,  chiefly 
methaemoglobin.  Red  corpuscles  are  absent  or  few  in  number.  The 
urine  is  smoky  or  brownish-red,  even  black,  and  upon  standing  deposits  a 
dense,  dirty  brown  sediment  made  up  of  granular  pigment,  the  detritus  of 
blood-corpuscles,  epithelium,  and  pigmented  urates. 

Three  forms  are  recognized:  the  toxic,  the  paroxysmal,  and  haemo- 
globinuria of  the  new-born. 

1.  Toxic  Hemoglobinuria. — This  variety  is  encountered  in  poison- 
ing by  those  agents  which  produce  rapid  destruction  of  the  erythrocytes. 


SYMPTOMS  AND  SIGNS:   REPRODUCTIVE  ORGANS.       569 

Important  among  these  are  potassium  chlorate,  urotropin,  pyrogallic  aeid, 
carbolic  acid,  arseniureted  hydrogen,  carbon  monoxide,  naphthol,  and  mus- 
carine. It  is  also  produced  by  the  transfusion  of  blood  from  one  mammal 
into  another,  by  exposure  to  intense  cold  and  violent  exertion,  and  occurs 
after  extensive  burns.  In  malarial  subjects  it  may  follow  the  administra- 
tion of  quinine — black  water  fever. 

2.  Paroxysmal  Hemoglobinuria.  —  An  affection  characterized  by 
the  occasional  passage  of  urine  colored  by  haemoglobin.  It  occurs  in  adults 
and  is  more  common  in  males  than  in  females.  The  paroxysms  are  excited 
by  cold  and  exertion  and  last  from  a  few  hours  to  a  day  or  two.  It  is  thought 
by  some  observers  to  have  an  essential  relationship  to  Raynaud's  disease; 
by  others  to  malaria.  Pain  in  the  lumbar  region  is  common.  The  attacks 
may  be  ushered  in  by  chills  followed  by  fever;  more  commonly  the  tem- 
perature is  normal  or  slightly  subnormal.  They  recur  at  irregular  intervals 
for  an  indefinite  time. 

3.  Epidemic  Hemoglobinuria  of  the  New-born.  —  The  disease 
develops  about  the  fourth  day  and  attacks  a  large  proportion  of  the  infants 
in  the  maternity  institution  where  it  appears.  There  is  bloody  urine  with 
vomiting  and  purging,  jaundice,  hurried  breathing,  and  cyanosis.  It  is 
rapidly  fatal.  Post-mortem  examination  reveals  enlargement  of  the  spleen 
with  punctiform  hemorrhages  upon  the  surface  and  in  the  parenchyma  of 
the  viscera.  This  disease  is  to  be  differentiated  from  icterus  neonatorum 
to  which  it  bears  only  a  superficial  resemblance. 

THE   REPRODUCTIVE   ORGANS. 

In  both  men  and  women  sexual  neurasthenia,  hypochondriasis,  and 
perversion  frequently  occur.  Ungratified  desire,  excessive  venery,  and 
unnatural  sexual  acts  are  more  commonly  the  alleged  than  the  actual 
causes  of  various  nervous  and  mental  diseases.  The  two  latter  are  prob- 
ably manifestations  more  often  than  causes  of  such  forms  of  disease. 
Irregular  manifestations  may  be  on  the  one  hand  psychical,  on  the  other 
physical;  frequently  they  are  both.  The  field  is  a  large  one  and  the  extent 
to  which  it  is  to  be  investigated  in  individual  cases  may  be  left  to  the  judg- 
ment of  the  clinician. 

The  history  or  the  actual  manifestations  of  venereal  disease  in  a 
patient,  or  in  an  individual  with  whom  the  patient  has  had  sexual  relations, 
are  often  of  great  importance  in  the  diagnosis  of  an  otherwise  obscure  case. 
A  gonorrhceal  discharge  may  solve  the  problem  of  an  obscure  and  intract- 
able arthritis  or  indicate  the  nature  of  serious  tubal  or  other  pelvic  disease, 
ami  explain  an  unlooked  for  ophthalmia  in  the  new-born.  Syphilitic  lesions 
or  the  scar  of  a  chancre  in  the  husband  may  be  the  key  to  the  solution  of 
obscure  nervous  symptoms  in  the  wife,  or  nutritional  disorders  and  lesions 
of  the  organs  of  special  sense  in  the  child. 

In  the  male,  priapism,  impotence  and  spermatorrhoea  occur  as  impor- 
tant manifestations  of  disease. 

(a)  Priapism. — This  term  is  used  to  designate  abnormally  frequent 
and  prolonged  erection.  The  condition  is  not  associated  with  libido  s(X'Kilis 
but  with  distress  and  pain  and  constitutes  a  morbid  symptom. 


570  MEDICAL  DIAGNOSIS. 

It  is  often  manifest  in  a  mild  degree  in  young  boys.  Even  at  the  age 
of  one  or  two  years  it  may  be  painful  and  distressing  and  often  leads  to 
enuresis  nocturna.  It  may  be  due  to  phimosis  and  disappear  after  circum- 
cision. In  the  adult  it  may  result  from  inflammatory  irritation  of  the  ure- 
thral mucosa.  It  may  follow  the  passing  of  a  bougie  and  is  very  common  in 
gonorrhoea  and  in  the  chronic  inflammation  of  the  prostatic  portion  of  the 
urethra  in  those  who  have  practised  masturbation  or  indulged  in  sexual 
excesses  or  irregularities.  The  condition  may  be  due  to  excessive  stimula- 
tion of  the  centre  in  the  lumbar  cord.  The  latter  form  comes  on  during 
sleep.  The  patient  awakes  with  intensely  painful  priapism  unattended  by 
the  slightest  libido  sexualis.  This  presently  subsides  only  to  return  when, 
under  the  influence  of  deep  sleep,  the  inhibition  of  the  special  spinal  centre 
is  withdrawn.  In  severe  cases  sleep  is  seriously  interrupted  and  the  annoy- 
ance of  the  patient  is  increased  by  the  discharge  of  a  thin  mucus  from 
Cowper's  glands  and  painful  neuralgia  in  various  parts  of  the  body.  This 
form  of  priapism  is  often  accompanied  by  impotence. 

Priapism  may  be  the  result  of  stone  in  the  bladder,  inflammation  of 
the  prostate,  a  perineal  abscess,  proctitis  or  periproctitis,  inflamed  hemor- 
rhoids, or  poisoning  by  cantharides.  It  is  said  to  be  symptomatic  of  certain 
forms  of  neurasthenia  and  hysteria.  It  is  a  common  symptom  in  fractures 
of  the  spine,  especially  when  the  cervical  portion  is  involved.  It  may  occur 
in  myelitis,  spinal  meningitis,  and  in  lesions  of  the  pons  and  cerebellum. 
It  occurs  in  hydrophobia  and  tetanus  and  has  frequently  been  observed 
in  leukaemia. 

(b)  Impotence— I mpotentia  Coeundi — This  symptom  may  be  me- 
chanical, psychical,  irritative,  or  paralytic. 

1.  Mechanical  impotence  arises  from  congenital  or  acquired  deformi- 
ties; loss  of  substance  from  ulceration,  gangrene,  or  operation;  the  presence 
of  tumors,  as  hydrocele,  enormous  hernia,  elephantiasis  of  the  scrotum,  and 
the  like.  To  this  list  must  be  added  hypertrophy  of  the  organ,  tumor  of 
the  glands,  preputial  or  urethral  calculi  and  defect,  atrophy  or  destruction 
of  the  testicles.  To  this  group  of  causes  is  to  be  added  deviation  of  the 
erect  penis  from  abnormally  short  frsenum  and  various  infiltrations  and 
indurations  in  its  tissues.  A  rare  cause  of  impotence  is  deformity  due  to 
ossification  of  the  fibrous  tissue  in  the  organ. 

2.  Psychical. — This  form  of  impotence  arises  from  apprehension, 
shame,  or  self-distrust.  It  may  occur  alike  in  those  who  have  made  too 
great  experience  and  in  those  who  have  made  none,  and  the  fear  of  it  fre- 
quently leads  men  about  to  marry  to  take  medical  advice.  It  is  sometimes 
due  to  indifference,  aversion,  or  dislike  towards  a  particular  person  and  in 
rare  instances  to  constitutional  lack  of  sexual  feeling. 

3.  Irritative. — There  is  premature  ejaculation  or  even  ejaculation  in 
the  absence  of  sexual  approach.  This  may  occur  in  healthy  individuals  after 
long  abstinence.  It  is  very  often  due  to  local  irritation,  to  lesions  resulting 
from  urethritis,  or  to  excesses.  The  subjects  are  usually  neurasthenic, 
the  nervous  condition  being  the  cause  in  some  cases,  in  others  the  effect 
of  the  sexual  irregularity. 

4.  Paralytic. — Under  this  heading  are  to  be  grouped  those  forms  of 
impotence  caused  by  the  loss  of  power  to  react  to  physiological  stimuli  on 


SYMPTOMS  AND  SIGNS:    REPRODUCTIVE  ORGANS.        571 

the  part  of  the  sexual  nerves  or  their  centres.  In  the  atonic  cases  anaemia 
and  relaxation  of  the  parts  are  present  and  the  patients  are  neurasthenic. 
Sexual  irregularities  and  excesses,  immoderate  indulgence  in  alcohol  and 
tobacco  are  causes.  Certain  drugs,  as  opium  and  its  derivatives,  nitre, 
the  salicylates  and  the  bromides,  taken  in  large  doses  or  for  long  periods 
of  time,  lead  to  this  form  of  impotence. 

Diseases  of  the  brain  and  spinal  cord  may  be  the  cause  of  paralytic 
impotence.  Tabes  dorsalis  and  other  affections,  characterized  by  im- 
paired function  of  the  bladder  or  rectum  or  by  local  anaesthesia,  are  espe- 
cially to  be  considered.  This  condition  is  also  symptomatic  of  diabetes 
mellitus,  obesity,  and  cachectic  states. 

(c)  Spermatorrhoea.  —  This  term  is  used  to  designate  the  patho- 
logical discharge  of  seminal  fluid  which  takes  place  without  erection  or 
sexual  sensation  during  the  act  of  micturition  or  defecation.  The  emissions 
which  occur  at  intervals  of  two  or  more  weeks  in  continent  young  men 
during  sleep,  and  which  are  accompanied  by  lascivious  dreams,  are  physio- 
logical rather  than  pathological  and  are  not  to  be  considered  under  this 
heading.  When,  however,  these  emissions  recur  at  short  intervals,  or 
every  night,  they  become  symptomatic  of  disease  and  the  border-line 
between  such  nocturnal  pollution  and  spermatorrhoea  is  no  longer  clearly 
defined.  Gonorrhoea,  onanism  and  sexual  excesses  are  liable  to  be  followed 
by  spermatorrhoea.  Constipation,  nervous  diarrhoea,  fissure  of  the  anus, 
seat-worms,  and  proctitis  may  act  as  accidental  causes.  The  patients  are 
neurasthenic  and  depressed,  complain  of  headache,  backache,  and  loss  of 
energy,  are  much  given  to  the  reading  of  advertisements  upon  loss  of  man- 
hood and  are  the  easy  pre 3^  of  quacks.  A  large  proportion  of  those  who 
think  they  are  victims  of  this  disease  do  not  have  it,  but  suffer  from  chronic 
gonorrhoea,  prostatorrhcea,  urethrorrhcea,  and  forms  of  phosphaturia. 
The  microscope  is  essential  to  the  diagnosis,  and  it  is  necessary  when  sper- 
matozoids  are  present  to  ascertain  whether  or  not  a  sexual  act  has  preceded 
the  emission  of  the  fluid  in  question.  If  not,  and  especially  if  spermato- 
zoids  are  present  upon  repeated  examination,  the  diagnosis  becomes  posi- 
tive. These  bodies  are  present  in  the  urine,  which  may  be  acid,  of  high 
specific  gravity,  and  contain  oxalates,  or  alkaline  with  phosphates. 

In  the  female  pruritus  vulvae,  leucorrhcea,  and  disorders  of  menstrua- 
tion may  be  symptomatic  of  various  local  and  general  conditions. 

(a)  Pruritus  Vulvae. — This  condition  is  a  common  result  of  inflam- 
matory affections  and  displacements  of  the  womb,  ovarian  disease,  and 
affections  of  the  urethra,  bladder,  and  kidneys.  It  is,  especially  in  children, 
a  common  manifestation  of  seat-worms  and  is  very  often  the  first  symp- 
tom of  the  diabetic  woman  to  attract  her  attention  to  her  condition.  This 
condition  on  the  one  hand  frequently  leads  to  masturbation;  on  the  other 
is  not  rarely  the  result  of  it. 

(b)  Leucorrhcea. —  Vaginal  discharge  is  an  important  sign  of  many 
pelvic  diseases.  It  is  associated,  very  often  in  connection  with  pelvic 
inflammations  of  mild  grade,  with  the  anaemias,  especially  when  intense, 
with  conditions  of  debility  and  the  later  stages  of  chronic  diseases  when 
they  occur  in  early  life  and  in  particular  with  pulmonary  tuberculosis.  In 
young  children  a  purulent  discharge  indicates  vulvitis  or  vaginitis,  which 


572  MEDICAL  DIAGNOSIS. 

may  be  due  to  trauma,  filth,  ascarides,  or  gonorrhoea.  In  middle  life  an  offen- 
sive sanguinolent  discharge  may  be  the  earliest  sign  of  carcinoma  uteri. 
(c)  Menstrual  Derangements. — The  normal  menstrual  function  may 
be  deranged  in  various  ways.  It  may  be  absent  for  a  time  or  cease  alto- 
gether— amenorrhcea;  abnormally  profuse — monorrhagia;  or  attended  with 
much  distress  and  pain — dysmenorrhea.  These  derangements  are  due  to 
local  and  to  constitutional  conditions. 

1.  Amenorrhcea. — Failure  in  the  function  may  be  a  manifestation  of 
arrested  development  of  the  ovaries  and  uterus.  The  interruption  of 
menstruation  may  be  physiological  or  pathological. 

Physiological  amenorrhcea  is  a  characteristic  sign  of  pregnancy  and 
usually  persists  during  lactation.  There  are  important  exceptions  to  both 
these  rules.  In  very  rare  instances  there  is  a  slight  menstrual  discharge 
during  the  first  two  or  three  months  of  gestation  and  many  women  men- 
struate regularly  during  the  period  of  nursing.  Amenorrhcea  occurs  in 
extra-uterine  fcetation. 

Pathological  amenorrhcea  is  observed  in  conditions  of  malnutrition, 
as  in  overworked  school-girls,  in  those  suffering  from  chlorosis,  and  in 
wasting  diseases,  as  enteric  fever,  tuberculosis,  diabetes,  and  exophthalmic 
goitre.  It  may  be  symptomatic  of  powerful  depressing  psychical  states, 
as  anxiety,  worry,  or  grief,  and  of  nervous  affections,  as  hysteria,  or  of 
melancholia  or  other  forms  of  insanity,  and  not  infrequently  occurs  in  young 
immigrants.  It  is  common  in  morphinism  and  other  drug  habits  and  in 
cachectic  states,  whether  due  to  chronic  intoxication,  as  by  mercury  or 
lead,  or  to  malaria,  cancer,  nephritis,  leukaemia,  or  profound  anaemia  from 
any  cause.  The  retention  of  the  flow  which  takes  place  in  cases  of  imper- 
forate hymen,  atresia  vaginae,  and  analogous  conditions  cannot  be  regarded 
as  a  form  of  amenorrhcea. 

Delay  in  the  establishment  of  menstruation  is  in  some  girls  consti- 
tutional and  often  hereditary;  its  early  cessation  may  in  some  instances  be 
accounted  for  upon  similar  grounds.  There  are  healthy  women  who  cease 
to  menstruate  at  thirty  or  thirty-five.  Premature  menopause  may  be  due 
to  atrophy  of  the  ovaries  following  disease  or  their  operative  removal. 

So-called  vicarious  menstruation,  namely,  the  monthly  discharge  of 
blood  from  the  nose,  lungs,  stomach,  from  hemorrhoids,  ulcers  or  wounds, 
in  the  absence  of  the  normal  flow,  is  described.  There  is  no  physiological 
basis  for  such  a  phenomenon  and  it  is  probable  that  in  the  cases  described 
the  conditions  causing  amenorrhcea  have  also  caused  hemorrhages,  the 
regular  periodicity  and  duration  of  which  have  corresponded  to  the  men- 
strual period  less  in  fact  than  in  fancy. 

2.  Menorrhagia. — Abnormally  profuse  menstruation  may  be  symp- 
tomatic of  disorders  of  the  pelvic  organs  or  of  constitutional  disease.  It 
occurs  in  a  great  variety  of  local  diseases  but  especially  in  chronic  endo- 
metritis, submucous  myomata,  polypi,  and  uterine  displacements.  Menor- 
rhagia is  an  occasional  symptom  in  haemophilia,  scurvy,  purpura  haemor- 
rhagica,  and  leukaemia.  When  menstruation  takes  place  in  the  course  of 
the  acute  infectious  diseases,  for  example  influenza,  enteric  fever,  or  variola, 
it  frequently  amounts  to  menorrhagia.  Other  conditions  in  which  this 
symptom  is  occasionally  observed  are  intense  jaundice,  phosphorus  poison- 


SYMPTOMS  AND  SIGNS:    REPRODUCTIVE  ORGANS.        573 

ing,  alcoholism,  cirrhosis  of  the  liver,  and  valvular  disease  of  the  heart. 
The  administration  of  certain  drugs,  as  ergot,  gossypium,  aloes,  and  the  oil 
of  savine,  is  sometimes  followed  by  menorrhagia.  Irregular  menstruation, 
sometimes  profuse,  not  infrequently  precedes  the  menopause. 

3.  Dysmenorrhea. — This  term  is  used  to  designate  collectively  the 
symptom-complex  in  difficult  menstruation  of  which  pain  is  the  chief 
element.  The  morbid  conditions  in  which  it  occurs  may  be  arranged  under 
two  headings,  affections  of  the  sexual  system  and  general  diseases. 

Under  the  first  heading  are  to  be  included  those  diseases  in  which  there 
is  an  obstruction  to  the  outflow  of  the  menstrual  fluid,  as  in  contraction  of 
the  internal  or  external  os  uteri,  congenital  narrowing  of  the  cervical  canal 
or  a  narrowing  acquired  as  the  result  of  flexions  of  the  uterus,  the  presence 
of  tumors  or  cicatricial  contractions  following  unwise  treatment.  This 
form  is  spoken  of  as  mechanical  dysmenorrhea.  Here  also  are  to  be  con- 
sidered the  dysmenorrheas  caused  by  irritable  or  inflamed  conditions  of 
the  mucosa  secondary  to  chronic  metritis,  displacements,  tumors  and 
disease  of  the  ovaries. 

Under  the  second  heading  we  include  the  dysmenorrhea  of  neurotic 
persons — neuralgic  or  nervous  dysmenorrhea.  This  form  is  common  alike 
in  badly-nourished,  ana?mic,  unmarried  women  and  in  women  who  have 
borne  children.  Very  frequently  no  adequate  lesions  of  the  pelvic  viscera 
can  be  discovered;  more  commonly  trifling  abnormalities  such  as  cause 
insignificant  symptoms  in  otherwise  well-nourished  and  healthy  women. 
The  patients  are  neurasthenic  and  frequently  hysterical.  The  symptoms 
vary  greatly.  In  many  cases  they  amount  merely  to  an  intensification  of 
the  ordinary  discomforts  which  attend  the  periodical  sickness;  in  others 
the  patient  may  writhe  with  anguish  or  manifest  the  most  intense  reflex 
phenomena  as  nausea,  vomiting,  headache,  or  convulsions.  Usually  these 
symptoms  subside  upon  the  establishment  of  the  flow;  sometimes  they 
continue  with  remissions  and  exacerbations  throughout  the  whole  period, 
and  in  some  cases  they  cease  entirely  only  to  recur  toward  the  close  of  the 
process. 

.Membranous  dysmenorrhea — decidua  menstrualis — a  form  of  dys- 
menorrhea in  which,  with  recurring  menstruation,  hollow  membranous 
casts  of  the  uterus  are  expelled  with  great  pain.  These  casts  consist  of  a 
thickened  menstrual  decidua.  They  vary  from  membranous  fragments  to 
complete  triangular  casts  of  the  interior  of  the  womb,  showing  the  openings 
of  t  he  tubes  and  the  internal  os.  They  are  usually  expelled  upon  the  second 
or  third  day,  sometimes  Later.  The  pains  are  paroxysmal  and  very  intense 
and  cease  immediately  upon  the  expulsion  of  the  membranes  from  the 
womb.  This  form  of  dysmenorrhea  is  sometimes  encountered  in  women 
suffering  from  chronic  metritis  or  endometritis.  It  is  very  chronic,  some- 
times com  inning  throughout  the  entire  menstrual  life  of  the  individual. 
Then-  is  complete  relief  during  the  intermenstrual  periods.  The  condition 
is  to  be  differentiated  from  early  abortion  and  extra-uterine  pregnancy. 

4.  Metrorrhagia. — An  abnormal  uterine  hemorrhage  is  to  be  distin- 
guished from  an  excessive  menstrual  discharge  or  menorrhagia,  with  which 
it  is,  however,  very  commonly  associated.  It  may  occur  in  diseases  of  the 
reproductive  organs  or  in  certain  general  affections.     Metrorrhagia  due  to 


574  MEDICAL  DIAGNOSIS. 

local  disease  usually  indicates  disease  of  the  uterus  and  mostly  the  presence 
of  new  growths,  namely,  carcinoma,  sarcoma,  or  fibroid  tumors.  The 
bleeding  in  carcinoma  at  first  takes  the  form  of  an  increased  menstrual 
flow  usually  more  and  more  prolonged  and  frequently  accompanied  by  a 
more  or  less  abundant  watery  discharge.  The  bloody  discharge  after  a 
time  persists  during  the  intermenstrual  periods  and  becomes  wholly  atyp- 
ical. The  occurrence  of  bleeding  in  women  who  have  passed  the  meno- 
pause is  very  suggestive  and  renders  an  examination  per  vaginam  at  once 
imperative.  The  metrorrhagia  of  sarcoma  and  in  particular  of  sarcoma 
involving  the  uterine  mucosa  presents  similar  characters.  Subserous 
fibromata  do  not  bleed.  Those  situated  in  the  substance  of  the  uterus,  if 
near  the  serous  surface,  bleed  little  or  not  at  all.  Submucous  fibromata 
bleed  more  or  less  freely.  Necrotic  changes  in  uterine  neoplasmata  are 
attended  by  a  foul-smelling  discharge  in  which  shreds  of  broken-down 
tissue  are  present.  The  atypical  bleedings  which  attend  inflammatory 
affections  are  less  frequent  and  Jess  profuse.  Those  which  are  caused  by 
mucous  polypi  are  often  profuse  and  continuous. 

Exceptionally  metrorrhagia  occurs  in  valvular  disease  of  the  heart, 
especially  mitral  stenosis,  and  is  said  to  have  been  observed  in  cirrhosis 
of  the  liver.  This  symptom  occurs  infrequently  in  the  acute  infectious 
febrile  diseases,  as  enteric  fever,  measles,  scarlet  fever,  variola,  cholera, 
and  malaria,  and  in  phosphorus  poisoning  and  scurvy.  In  the  last  the 
blood  loss  is  sometimes  copious.  Difficulties  arise  in  the  differential  diag- 
nosis of  the  cause  of  the  bleeding  when  the  patient  suffering  from  the 
foregoing  diseases  has  also  local  conditions  in  themselves  capable  of  caus- 
ing metrorrhagia  or  when,  during  the  acute  illness  or  shortly  before  its 
onset,  an  abortion  or  miscarriage  has  taken  place. 


XIII. 

GENERAL  SYMPTOMATIC  DISORDERS  OF  THE 

NERVOUS  SYSTEM. 

PAIN. 

Pain  is  a  symptomatic  sensory  neurosis.  The  pain  sense  is  to  be  dis- 
tinguished from  the  tactile  sense,  the  pressure  sense,  and  the  thermal  sense. 
It  is,  however,  so  closely  associated  with  the  last  two  that  a  considerable 
degree  of  pressure,  unusual  heat,  or  intense  cold  is  accompanied  by  pain. 
Pain  is  in  the  strictest  sense  a  symptom.  It  is  purely  subjective,  hence  its 
value  in  diagnosis  is  to  a  large  degree  dependent  upon  the  individual 
peculiarities  of  the  sufferer,  the  nature  of  the  primary  lesion  or  disease,  and 
concomitant  phenomena,  many  of  which  are  objective.  Judged  by  these 
standards  pain  is  a  symptom  of  the  most  varied  intensity,  from  a  trifling 
discomfort  without  direct  diagnostic  significance  to  agony  so  extreme  as 
to  cause  death.  The  pain  sense  is  universally  distributed  throughout  the 
body,  the  only  structures  in  which  it  is  wholly  lacking  being  the  hair  and 


SYMPTOMS  AND  SIGNS:    PAIN.  575 

nails.  Variations  in  the  pain  sense  in  different  localities,  probably  due  to 
modifications  in  the  sensory  nerve  supply,  must  be  invoked  in  explanatiop 
of  the  different  kinds  of  pain  in  the  various  viscera  and  other  anatomical 
structures.  Etiological  factors  of  the  most  diverse  kind  have  to  do  with 
pain  in  its  relation  to  time,  as  shown  in  its  onset,  course,  and  decline. 

Pain  is  dependent  upon  consciousness.  In  profound  coma,  as  that  of 
surgical  ansesthesia,  consciousness  and  pain  are  alike  wholly  abolished. 
When  consciousness  is  less  completely  impaired  there  are  objective  mani- 
festations of  painful  impressions,  though  the  patient,  upon  recovering, 
may  have  no  recollection  of  pain.  Pain  may  be  absent  in  shock.  Individ- 
uals usually  make  no  complaint  of  pain  during  the  period  of  shock  follow- 
ing gun-shot  wounds  or  other  severe  traumatism.  Under  these  circum- 
stances pain  comes  on  as  shock  subsides. 

Etiology. — Pain  is  functional  or  organic.  The  temporary  pain  in  over- 
worked muscles  is  functional.  The  pain  in  pleurisy  and  gastric  ulcer  is 
organic.  Pain  occurs  as  a  more  or  less  prominent  symptom  under  the 
following  conditions: 

1.  Excessive  or  unduly  prolonged  physiological  activity,  either 
physical^  as  in  muscular  strain  or  fatigue,  or  psychical,  as  in  the  head- 
ache which  follows  undue  intellectual  effort.  The  pains  of  parturition 
are  physiological. 

2.  Traumatism  of  all  kinds. 

3.  Circulatory  disturbances,  (a)  Passive  congestion.  An  example  of 
pain  thus  caused  is  to  be  found  in  thrombosis  of  the  crural  vein,  formerly 
known  as  phlegmasia  alba  dolens.  (b)  Active  hyperemia,  for  example,  the 
cutaneous  pain  of  local  irritants,  as  heat,  cold,  mustard  and  the  like.  Pain 
in  the  region  of  the  spleen  after  running  is  an  example  of  visceral  pain  due 
to  this  cause,  (c)  Anaemia.  Examples  of  this  form  of  pain  are  headache 
upon  exertion  and  the  neuralgias. 

4.  Inflammation.  Pain  is  a  prominent  symptom  in  all  forms  of 
inflammation. 

5.  Toxaemia.  The  offending  substance  or  substances  in  the  blood 
may  be  the  result  of  (a)  infection,  as  in  the  acute  specific  fevers  and  malaria; 
(b)  incomplete  or  perverted  physiologicochemical  processes  or  the  defec- 
tive elimination  of  waste,  as  in  the  headache  of  uraemia  and  diabetes  and 
the  pains  of  gout,  rheumatism,  and  lithaemia;  (c)  the  action  of  drugs  or 
poisons.  Pain  due  to  this  cause  may  be  hyperaemic,  as  in  the  head  pain 
produced  by  amyl  nitrite  and  quinine;  inflammatory,  as  in  the  later  stages 
of  narcotic  poisoning;  purely  nervous,  as  an  abstinence  symptom  in  mor- 
phinism and  the  pains  of  the  chloral  habit  and  lead  colic. 

().  Changes  in  the  arteries.  Examples  of  pain  due  to  tin's  cause  are 
found  in  syphilis,  chronic  alcoholism,  chronic  lead  poisoning,  migraine, 
and  aneurism.  To  this  general  topic  must  also  be  referred  the  pain  in 
intermittent  claudication  and  angina  pectoris. 

7.  All  organic  painful  diseases,  abscess,  tumor,  both  benign  and 
malignant,  and  various  diseases  of  the  viscera,  whether  the  pain  be  due  to 
changes  in  the  organ  itself  or  disturbance  of  adjacent  structures  by  pres- 
eure  or  displacement. 

R.    Caries  and  other  diseases  of  the  bones. 


576  MEDICAL  DIAGNOSIS. 

9.  Neuropathic  conditions,  for  example,  neurasthenia,  hysteria,  tabes, 
dysmenorrhea,   and  tetanus. 

10.  Reflex  irritation,  as  the  supra-orbital  pain  in  indigestion  and  the 
various  localized  head  pains  of  eye-strain,  pain  in  the  external  auditory 
meatus  in  dental  irritation,  and  coccygodynia  in  uterine  disease.  Anal- 
ogous are  the  pains  in  the  knee  which  occur  in  hip-disease  and  painful 
sensations  due  to  the  irritation  of  the  nerve  stump  referred  to  the  hand  or 
foot,  as  the  case  may  be,  in  an  amputated  limb. 

The  cause  of  pain  is  very  often  simple.  In  many  cases,  however,  it  is 
complex,  two  or  more  of  the  foregoing  factors  being  operative. 

Mode  of  Expression  cf  Pain. — Pain  must  be  studied  subjectively, 
as  we  experience  it  in  our  own  person,  and  objectively,  as  manifested  by 
the  movements,  attitudes,  and  verbal  descriptions  of  the  sufferer. 

Subjectively  we  know  that  certain  external  impressions  give  rise  to 
the  sensation  of  pain  and  that  this  sensation  is  accompanied  by  movements 
of  withdrawal  from  the  object  causing  the  pain,  by  particular  attitudes  of 
the  body  and  contortions  of  the  facial  muscles.  Under  certain  circumstances 
there  are  inarticulate  sounds,  cries  or  groans  expressive  of  pain;  these 
phenomena  are  varied  according  to  the  suddenness  and  the  intensity  of  the 
pain  and  its  character. 

Objectively  we  recognize  in  these  phenomena  a  manifestation  of  pain 
in  others.  The  gestures  that  are  characteristic  of  different  varieties  of  pain 
have  been  described  by  W.  H.  Thomson.  In  pains  due  to  inflammation 
the  patient  avoids  touching  the  painful  part,  or  approaches  it  very  cau- 
tiously. Thus  the  hand  passes  over  an  inflamed  joint  with  a  hovering 
gesture.  If  the  pain  be  deeper  seated  the  gestures  are  indicative  of  its 
distribution  and  the  character  of  the  inflamed  tissue.  Thus  the  substernal 
pain  of  bronchitis  as  indicated  by  the  whole  hand  laid  upon  the  sternum 
and  passed  over  the  chest.  In  pleurisy  the  location  of  the  pain  is  indicated 
by  the  tips  of  the  straightened  fingers,  the  natural  gesture  expressive  of 
the  stabbing  or  lancinating  character  of  the  pain.  Precordial  pain,  if 
severe,  is  indicated  by  the  tips  of  the  bent  fingers.  The  gestures  by  which 
abdominal  pain  is  indicated  are  equally  significant.  In  pains  associated 
with  lesions  of  the  intestines  the  open  hand  is  passed  over  the  abdomen 
with  a  rotary  movement.  -  In  the  localized  pain  of  appendicitis  the  open 
hand  is  held  over  the  affected  area  with  the  fingers  lightly  flexed.  In  peri- 
tonitis the  tips  of  the  fingers  are  used  but  they  touch  the  surface  very  gently 
and  cautiously.  Local  pains  resulting  from  visceral  disease  or  colic  are 
indicated  by  less  guarded  gestures;  radiating  pains  by  a  repeated  sweep 
ot  the  hand  in  the  same  direction;  distention  pains  and  colic  by  a  firm 
pressure  upon  the  abdomen;  neuralgic  pains  by  repeated  firm  pressing 
movements  of  the  hand  in  the  direction  of  the  involved  nerve.  The  light- 
ning pains  of  tabes  are  often  indicated  by  a  quick  sweep  of  the  tips  of  the 
fingers  along  the  limb. 

The  shrinking  of  the  whole  body  or  of  a  member  from  an  object  ca- 
pable of  causing  or  increasing  pain  is  a  characteristic  gesture;  so  also  is  the 
limping  gait  in  painful  conditions  of  a  lower  extremity.  For  diagnostic 
purposes  it  is  important  to  bear  in  mind  the  fact  that  limping  is  frequently 
due  to  restricted  movement  not  necessarily  accompanied  by  pain.     Very 


SYMPTOMS  AXD  SIGNS:   PAIX.  577 

characteristic  are  the  attitudes  in  certain  painful  affections:  retraction 
of  the  head  in  meningitis,  the  shallow  breathing  and  flexion  of  the  trunk 
toward  the  affected  side  in  plastic  pleurisy,  the  strong  bending  forward  in 
colic,  the  rigid  trunk  and  flexed  thighs  in  peritonitis,  the  semiflexion  and 
immobilization  of  inflamed  joints. 

Sudden  immobility  of  the  whole  body  is  diagnostic  of  angina  pectoris. 

The  facies  of  pain  constitutes  a  most  important  objective  manifesta- 
tion, whether  it  be  the  contorted,  dusky  pale  face  of  sudden  agony  or  the 
drawn  and  pallid  countenance  of  prolonged  and  repeated  suffering.  Severe 
pain,  especially  when  paroxysmal,  is  frequently  accompanied  by  dilatation 
of  the  pupils,  rapid  respiration,  flushing  or  pallor,  free  sweating,  increased 
arterial  tension,  and  sensations  of  faintness.  Inarticulate  sounds  and  invol- 
untary exclamations  are  familiar  objective  manifestations  of  sudden  and 
intense  pain. 

Swine  of  the  objective  manifestations  of  pain  are  involuntary  and 
cannot  be  simulated;  others  may,  with  or  without  the  conscious  intention 
to  deceive,  be  feigned  or  exaggerated.  By  the  verbal  description  we  gain 
information  as  to  the  location,  character,  intensity,  and  duration  of  pain, 
and  the  patient's  opinion  as  to  its  cause.  The  accounts  are  much  modified 
by  the  temperament,  power  of  expression,  and  general  experience  of  the 
sufferer. 

Not  only  the  ability  to  express  the  subjective  sensation  of  pain  varies 
greatly  but  also  the  susceptibility.  There  are  on  the  one  hand  individuals 
in  whom  the  pain  sense  is  but  slightly  developed;  on  the  other  those  in 
whom  it  is  present  to  an  abnormal  and  excessive  degree. 

There  are  racial  differences  in  the  susceptibility  to  pain  and  the  mode 
of  expressing  painful  sensations.  The  Latin  races  manifest  a  greater  sus- 
ceptibility to  pain  than  the  Anglo-Saxons.  Oriental  apathy  is  proverbial. 
On  the  other  hand  Hebrews  appear  to  have  a  peculiar  susceptibility  to  pain. 

The  individual  susceptibility  is  much  modified  by  temperament. 
Phlegmatic  persons  suffer  less  and  show  such  sufferings  as  they  experience 
much  less  forcibly  than  those  of  sanguine  or  nervous  temperament.  The 
neurotic  individual  suffers  in  proportion  to  the  instability  of  his  nervous 
organization.  The  pains  of  hypochondria  and  hysteria  are  probably  of 
central  origin.  They  are  of  irregular  distribution,  inconstant,  and  occur 
independently  of  the  recognized  causes  of  pain.  They  are  probably  none 
the  Less  real.  The)'  diminish  in  intensity  or  disappear  when  the  patient's 
attention  is  diverted  from  them  and  are  aggravated  by  suggestion.  The 
painful  aura  of  epilepsy  is  also  of  central  origin.  Fright,  expectation,  and 
dread  intensify  painful  impressions. 

Somewhat  analogous  to  the  influence  of  temperament  is  that  of  the 
power  of  expression.  The  manifestations  of  pain  are  sometimes  much  less 
marked  in  the  rude  and  uneducated  than  those  in  the  higher  walks  of  life. 
Apathy  is  a  Btriking  mental  condition  in  hospital  patients. 

Experience  is  not  less  important.  Habitual  exposure  i<>  hardship 
benumbs  the  pain  sense.  On  the  other  hand  a  life  of  refinement  and  luxury 
exalts  it.  Prolonged  suffering  or  frequenl  recurrence  of  painful  sensations 
augments  the  sensibility  and  each  recurrence  becomes  less  endurable. 
There  is  a  popular  phrase  to  the  effect  that  the  patient  is  worn  out  with  pain 


578  MEDICAL  DIAGNOSIS. 

The  manifestations  of  painful  sensations  are  much  influenced  by  cir- 
cumstance and  motive.  Consciousness  of  pain  is  greatly  diminished  during 
intense  religious  or  other  excitement  and  upon  the  field  of  battle.  When 
the  excitement  subsides  pain  asserts  itself.  The  repression  of  the  mani- 
festations of  pain  by  religious  fanatics,  the  stoicism  of  captives  under  tor- 
ture, and  the  fortitude  with  which  the  brave  endure  suffering  set  common 
experience  at  naught  and  emphasize  the  purely  subjective  nature  of  pain 
as  a  S}^mptom.  Not  uncommonly  patients  understate  their  sufferings 
either  from  motives  of  pride  or  reserve  or  in  order  to  avoid  operation  or 
treatment.  On  the  other  hand  patients  frequently  appear  to  overstate 
their  sufferings  in  order  to  secure  sympathy  or  for  other  obvious  motives. 
Women  are  more  susceptible  to  pain  than  men  and  according  to  circum- 
stances manifest  it  with  greater  intensity  or  endure  it  with  greater  fortitude. 

The  patient's  description  of  his  sufferings,  the  character  of  the  con- 
comitant phenomena,  and  the  presence  of  an  obvious  cause  will  enable  the 
physician  to  form  an  estimate  of  the  significance  of  pain.  In  young  chil- 
dren, in  certain  forms  of  insanity,  and  under  other  circumstances  in  which 
patients  are  unable  to  describe  their  sensations  the  objective  manifestations 
of  pain  are  of  diagnostic  value  in  determining  its  seat  and  intensity.  The 
physician  must  be  on  his  guard  in  any  particular  case  against  under-esti- 
mating the  importance  of  pain  or  being  deceived  by  its  unintentional  or 
purposeful  exaggeration. 

Varieties  of  Pain. — Pain  in  the  broadest  sense  may  be  considered  as 
parenchymatous  or  neuralgic.  In  the  former  the  terminal  sensory  fila- 
ments are  irritated;  in  the  latter  the  nerve-trunks,  the  sensory  roots,  or  the 
sensory  centres.  Parenchymatous  pain  is  as  a  rule  less  intense  than  neu- 
ralgic pain  and  the  spontaneous  remissions  are  less  marked.  In  the  former 
the  pain  in  the  whole  affected  region  is  increased  by  pressure,  while  in  the 
latter,  though  in  some  cases  the  entire  region  is  tender  under  pressure, 
the  general  rule  is  that  the  tenderness  is  localized  to  the  course  of  the  nerve- 
trunk,  especially  when  it  is  superficial  or  overlies  a  bone  or  makes  its  exit 
through  dense  fascia? — so-called  tender  points.  An  example  of  parenchym- 
atous pain  is  that  which  occurs  in  visceral  diseases  and  the  diffuse  head- 
aches; examples  of  neuralgic  pains  are  the  various  actual  neuralgias  which 
occur  as  primary  affections  in  persons  otherwise  in  fair  health,  in  the  ca- 
chectic and  broken-down,  and  as  secondary  affections  in  gout,  syphilis,  and 
diabetes  and  the  lightning  pains  of  spinal  disease,  especially  tabes.  The 
pains  originating  from  suggestion  and  autosuggestion  and  many  of  the 
forms  of  hysterical  pain  are  of  central  origin  and  may  be  regarded  as 
parenchymatous. 

Pain  has  been  described  as  acute,  sharp,  lancinating,  dull,  throbbing, 
grinding,  shooting,  burning,  chilling,  shivering,  boring,  creepy,  griping  or 
colicky,  itching  and  formicating.  These  descriptive  adjectives  indicate  not 
so  much  distinct  variations  in  the  quality  of  pain  as  the  simultaneous 
recognition  of  other  associated  sensations;  hence,  the  descriptions  of  pain 
are  often  complex  or  picturesque  in  proportion  to  the  vividness  of  the 
patient's  imagination  and  his  powers  of  expression. 

(a)  Acute  Pain — Sharp,  Lancinating,  or  Stabbing. — These  adjec- 
tives are  employed  to  describe  the  pain  which  attends  acute  inflammations 


SYMPTOMS  AND  SIGNS:    PAIN.  579 

of  serous  membranes,  as  pleurisy,  pericarditis,  and  peritonitis;  the  pains 
of  acute  arthritis;  acute  neuralgias;  the  painful  forms  of  neuritis;  acute 
phlegmonous  inflammation,  and  the  pains  of  thoracic  aneurism.  The 
lightning  pains  of  tabes  belong  to  this  group  and  are  characterized  by 
their  suddenness,  brief  duration,  and  intensity.  They  are  sometimes  spoken 
of  as  shooting  pains. 

(b)  Dull  pain  is  symptomatic  of  inflammation  of  the  mucous  mem- 
branes and  the  viscera.     It  occurs  also  in  chronic  inflammations. 

(c)  Throbbing  or  pulsating  pain  is  encountered  in  acute  superficial 
phlegmonous  inflammations.     This  is  the  pain  of  whitlow — paronychia. 

(d)  Grinding,  burning,  or  gnawing  are  adjectives  used  to  describe 
the  pain  which  occurs  in  diseases  of  the  bones  and  periosteum,  in  aneurism 
of  the  thoracic  and  abdominal  aorta,  in  carcinoma  of  the  viscera  and  of 
the  breast.  Pain  of  this  kind  sometimes  occurs  in  lithaemic  conditions  and 
in  the  later  stages  of  acute  gout.  The  localized  neuralgic  pain  in  the  head, 
known  as  clavus,  and  the  persistent  local  pains  which  occur  in  some  forms 
of  tabes  are  described  as  boring. 

(e)  Aching  pains  are  not  unlike  the  preceding.  They  are  usually 
persistent  and  intense  and,  when  severe,  throbbing.  Aching  is  a  term 
used  to  describe  pains  in  the  head,  those  resulting  from  dental  caries 
and  forms  of  neuritis  and  myalgia,  especially  lumbago — hence,  cephalalgia, 
odontalgia,  rhachialgia.  The  pains  which  occur  in  the  initial  period  of 
acute  infectious  diseases,  as,  for  example,  variola,  influenza,  and  dengue, 
and  are  referred  to  the  bones  and  muscles,  are  of  this  character.  They 
are  frequently  associated  with  painful  sensations  of  chilling  or  shiver- 
ing and,  since  they  spread  from  one  part  to  another,  are  often  described 
as  creeping. 

(f)  Burning  pain  occurs  in  the  superficial  cutaneous  lesions  caused 
by  intense  heat  or  the  action  of  the  sun's  rays,  and  caustic  applications. 
It  is  characteristic  of  certain  forms  of  neuritis.  Circumscribed  neuralgias 
are  frequently  associated  with  the  sensation  of  burning  pain — causalgia. 

(g)  Itching  pain  occurs  in  irritable  states  of  the  mucous  membranes, 
such  as  attend  certain  forms  of  conjunctivitis,  some  acute  diseases  of  the 
upper  air-passages,  and  hay  fever  and  some  forms  of  inflamed  hemorrhoids. 
Formication  is  a  term  used  to  describe  a  sensation  like  that  of  ants  or  other 
insects  crawling  over  the  skin.     It  is  occasionally  painful. 

(h)  Griping  or  colk  kv  pains  are  those  which  attend  the  overaction 
of  the  muscular  walls  of  tubal  structures.  Flatulent  or  other  distention 
of  the  stomach  or  intestines  induces  pain  of  this  kind — popularly  gripes 
or  belly-ache.  The  pains  upon  overaction  of  the  muscular  wall  of  the  intes- 
tines caused  by  indigestible  food,  cathartic  drugs,  irritant  poisons,  and 
certain  infections,  as  those  of  cholera  morbus  and  cholera  Asiatica,  are 
colicky.  To  this  group  belong  also  the  intense  paroxysmal  pains  which 
attend  the  passage  of  hepatic  and  renal  calculi — biliary  colic;  renal  colic. 
These  pains  are  frequently  spoken  of  as  cramp,  a  term  also  applied  to 
painful  contraction  of  the  skeletal  muscles,  as  those  of  the  calf,  toes,  fin- 
gers, the  pains  of  tetanus  and  strychnine  poisoning  and  those  which  occur 
in  habitually  over-used  muscles  in  certain  occupations — writer's  cramp, 
piano-player's  cramp. 


580  MEDICAL  DIAGNOSIS. 

(i)  Tenesmus  is  the  term  used  to  describe  the  painful  bearing-down  or 
straining  sensations  which  accompany  expulsive  efforts  from  the  outlets 
of  the  pelvic  organs  under  certain  abnormal  conditions,  as  urination  when 
there  is  acute  inflammation  of  the  bladder,  urethra,  or  prostate  gland,  or 
stricture;  defecation  in  proctitis  or  inflamed  piles  or  hydatid  or  other 
tumors  compressing  the  rectum.  The  bearing-down  pains  of  labor  are 
tenesmic. 

Pain  is  modified  by  physical  and  psychical  influences.  Among  the 
former  are  pressure,  mechanical  irritation,  movement,  and  rest. 

Modifications  by  Physical  Causes. — The  pain  which  is  caused  by 
pressure  and  the  increase  of  pain  upon  pressure  are  described  as  tenderness. 
This  will  be  discussed  later  under  a  separate  heading. 

Mechanical  irritation  causes  pain  or  aggravates  it  in  inflammation 
and  ulceration  of  mucous  membranes,  as  in  aphthous  and  other  forms  of 
stomatitis,  angina  tonsillaris,  peptic  ulcer  and  fissure  of  the  anus,  inflamed 
hemorrhoids,  and  in  various  lesions  of  the  tegumentary  structures.  Even 
slight  mechanical  irritation  of  the  normal  mucous  membrane  of  the  orifices 
of  the  body  causes  pain,  as  the  presence  of  a  minute  foreign  body  under 
the  eyelid,  the  introduction  of  a  probe  into  the  nasal  chambers,  or  the 
passing  of  an  urethral  bougie. 

Movement  aggravates  the  pain  of  wounds,  fractures,  and  inflammations. 
The  pain  which  attends  acute  inflammation  of  serous  membranes  is  espe- 
cially increased  upon  movement,  as  is  to  be  observed  upon  full  inspiration 
in  pleurisy  and  upon  flexion  and  extension  of  the  thigh  in  peritonitis. 
Movement  intensifies  the  pain  of  arthritis,  hence  the  involuntary  immobili- 
zation of  the  joints  and  the  relief  afforded  by  splints.  Movement  also  greatly 
increases  the  pains  of  vertebral  disease  and  neuritis.  The  pains  of  myalgia 
and  of  all  acute  inflammations  involving  the  muscles  are  augmented  by 
movement  of  the  affected  part.  In  many  instances  the  pains  of  inflamma- 
tory conditions  and  of  visceral  disease  are  increased  by  the  motion  of  the 
body  in  transportation. 

Rest,  upon  the  contrary,  is  commonly  attended  with  remission  of  pain; 
functional  rest,  by  its  temporary  disappearance,  as  in  myalgia,  the  headache 
of  eye-strain,  headache  from  prolonged  study,  and  the  pain  of  gastric  ulcer. 
The  foregoing  facts  indicate  the  value  of  attitude,  posture,  and  movement 
in  determining  the  diagnostic  significance  of  pain. 

Cold  and  heat  modify  pain.  Hot  applications  are  usually  soothing; 
cold  applications  only  occasionally  afford  relief.  The  application  of  heat 
or  cold  to  the  spine  may  indicate  the  level  of  disease  by  local  intensification 
of  pain.  Applications  of  heat  or  cold  frequently  enable  the  dentist  to 
locate  the  offending  tooth  in  diffuse  pain  involving  the  distribution  of  the 
dental  branches  of  the  fifth  nerve. 

Seasonal  influences  modify  habitual  tendencies  to  pain.  The  pains  of 
chronic  arthritis,  gout,  and  neuralgia  are  worse  in  cold  and  damp  weather, 
better  when  it  is  warm  and  dry.  The  influence  of  climate  upon  such  chronic 
painful  affections  is  similar;  dry,  equable,  warm,  inland  climates  being 
more  favorable  than  those  of  the  opposite  characteristics. 

Modifications  by  Psychical  Causes. — Among  the  psychical  influences 
which  modify  pain  and  its  manifestations,  intense  emotion,  excitement, 
pride,  and  fortitude  have  already  been  mentioned.     Other  influences  of 


SYMPTOMS  AND  SIGNS:    PAIN.  581 

more  importance  in  diagnosis  are  diversion,  preoccupation,  expectant 
attention,  suggestion,  and  autosuggestion.  They  may  be  active  under 
certain  circumstances  and  to  some  extent  in  almost  any  kind  of  pain;  but 
they  are  agencies  of  especial  importance  in  neurotic  persons  and  in  those 
suffering  from  hysteria,  neurasthenia,  and  hypochondriasis.  Not  only  are 
the  pains  for  which  there  are  no  obvious  physical  causes  augmented  or 
diminished,  or  made  to  disappear  or  shift  to  other  parts,  by  purel}'  psychical 
influences,  but  even  those  which  attend  actual  injury  and  manifest  disease 
may  be  greatly  modified  for  a  brief  period  of  time.  In  the  hypnotic  state 
pre-existing  pain  may  be  made  to  disappear  and  definite  pain  aroused 
with  readiness.  It  is  evident  that  persons  of  great  determination  may 
inhibit  the  manifestation  of  pain  under  the  stress  of  powerful  motives. 
There  are  also  rare  individuals  who  appear  to  be  able  to  inhibit  the 
sensation  of  pain. 

Time. — Pain  in  relation  to  time  may  be  occasional,  constant,  persistent, 
intermittent,  recurrent,  or  paroxysmal.  Pain  that  continues  for  any  length 
of  time  shows  marked  remissions  and  exacerbations.  The  remissions  are 
due  to  functional  exhaustion  of  the  pain  sense. 

Distribution. — Pain  may  be  (a)  diffuse  or  general,  or  (b)  circum- 
scribed or  local. 

Diffuse  paix  is  symptomatic  of  the  stage  of  onset  in  the  majority 
of  the  acute  febrile  infections.  It  varies  in  intensity  from  a  mere  sense  of 
malaise  or  general  soreness,  as  in  enteric  fever,  to  the  severe  aching  of 
influenza,  dengue,  or  variola.  It  occurs  also  in  angina  tonsillaris,  partic- 
ularly the  lacunar  form,  and  in  trichiniasis.  Diffuse  pains  attend  certain 
stages  of  some  chronic  diseases,  as  syphilis,  lithaemia,  and  saturnine  and 
mercurial  intoxication.  They  are  sometimes  described  as  vague  and  are 
often  shifting.  They  are  probably  peripheral  in  origin  and  due  to  the 
action  upon  the  nervous  system  of  toxic  substances  in  the  blood. 

Circumscribed  or  local  pain  occurs  as  a  symptom  in  the  greatest 
variety  of  morbid  conditions.  It  is  in  fact  the  most  common  and  most 
important  of  the  subjective  manifestations  of  disease.  Its  value  in  diag- 
nosis depends  largely  upon  the  ability  of  the  physician  to  estimate  the  ac- 
curacy of  the  verbal  description,  the  spontaneity  of  the  accompanying 
objective  phenomena,  the  anatomical  relationships  of  the  pain  itself,  the 
underlying  pathological  process,  and  the  importance  of  alleged  or  manifest 
causes.  Pain,  and  in  particular  local  pain,  may  be  a  danger  signal,  a  sign 
post,  a  gauge  of  the  progress  or  extension  of  disease,  a  counter  check  to 
objective  phenomena,  or  it  may  be  to  the  unwary  or  ill-informed  physician 
a  delusion  and  a  snare. 

Feigned  Pain. — The  simulation  of  pain  is  common  enough  in  malinger- 
ing, neurasthenia,  and  hysteria.  The  motives  of  malingering  are  innumer- 
able. In  neurasthenia  and  hysteria  they  usually  consist  of  a  morbid  crav- 
ing for  sympathy.  The  detection  of  simulated  pain  is  in  some  cases 
attended  with  difficulties  that  are  insurmountable.  In  malingering  the 
simulation  of  pain  is  usually  overdone.  The  distribution  <>f  the  pain  does 
not  conform  to  known  anatomical  rules.  Suggestion  is  of  importance.  The 
objective  phenomena  commonly  associated  with  intense  pain  are  wanting 
or  incongruous. 


582  MEDICAL  DIAGNOSIS. 

To  properly  estimate  the  value  of  pain  in  an  obscure  case  it  is  some- 
times desirable  to  have  the  patient  under  the  close  observation  of  an  experi- 
enced nurse  or  attendant  or  in  a  hospital  for  some  days. 

Significance  of  Pain. — In  general  terms  local  pain  is  symptomatic  of 
disease  of  the  part  to  which  it  is  referred.  Organic  headache,  angina  ton- 
sillaris, the  pain  in  the  side  in  pleurisy,  in  the  abdomen  in  peritonitis,  in 
the  joints  in  arthritis,  and  various  forms  of  pain  due  to  traumatism,  are 
examples  of  the  relationship  of  local  pain  to  local  disease.  As  regards  the 
anatomical  structure  involved  pain  may  be  tegumentary,  muscular,  osseous, 
visceral,  or  neural.  Very  commonly  the  pain  is  also  limited  to  the  region  or 
organ  affected.  But  there  are  numerous  exceptions  to  these  statements, 
and  we  find  local  pain  frequently  symptomatic  of  a  pathological  process  in 
a  distant  part,  or  local  disease  causing  pain  in  an  extended  area.  The 
recognition  of  these  facts  is  of  cardinal  importance  in  estimating  the  value 
of  local  pain  in  diagnosis. 

Referred  Pain. — A  familiar  example  is  the  intense  pain  over  the  supra- 
orbital notch  sometimes  felt  upon  eating  an  ice.  The  organ  affected  is 
probably  the  stomach,  the  location  of  the  pain  being  determined  by  the 
association  of  sensory  nerves  from  that  organ  with  the  trifacial.  Very 
curious  instances  of  referred  pain  have  been  reported — a  case  in  which 
rubbing  the  forearm  caused  pain  in  the  chest;  another  in  which  rubbing 
or  pinching  a  mole  on  the  leg  was  attended  by  sharp  pain  in  the  chin. 

Referred  pains  manifest  themselves  in: 

1.  Symmetrical  Areas. — A  case  is  reported  by  Mitchell  in  which  a 
shell-wound  of  the  right  foot  at  once  gave  rise  to  burning  pain  in  both  feet. 
A  shell-wound  of  the  left  thigh  caused  an  immediate  reference  of  pain  to 
the  same  area  on  both  sides,  so  that  the  patient  supposed  he  was  shot 
through  both  thighs.  Again,  an  injury  to  the  median  and  ulnar  nerves_  was 
attended  by  pain  in  the  opposite  hand. 

Allochiria  is  the  name  given  to  the  phenomenon  of  pain  or  other  sen- 
sation referred  to  a  symmetrical  area.  It  has  been  observed  in  tabes  and 
in  postdiphtheritic  neuritis. 

2.  Functionally  Associated  Organs.  —  Pain  in  the  mammae  is 
common  in  congestion  of  the  pelvic  organs  and  dysmenorrhea;  pain  in 
the  glans  penis  or  testicle  iri  renal  colic;  diffuse  pain  in  the  abdomen  in  the 
early  stage  of  appendicitis. 

3.  Segmental  Areas.  —  Visceral' disease  is  frequently  attended  by 
pain  and  tenderness  referred  to  areas  corresponding  to  the  nerve  supply 
of  a  given  spinal  segment.  The  affected  organs  receive  their  sensory  nerve- 
fibres  from  the  same  segment  of  the  spinal  cord  from  which  arise  the  fibres 
of  the  sensory  areas  to  which  the  pain  is  referred.  In  the  words  of  Head: 
"  As  the  sensory  and  localizing  power  of  the  surface  of  the  body  is  enor- 
mously in  excess  of  that  of  the  surface  of  the  viscera,  an  error  of  judgment 
occurs,  the  diffusion  area  being  accepted  by  consciousness  and  the  pain 
referred  to  the  surface  of  the  body  instead  of  to  the  organ  actually  affected." 
Hence  the  pain  in  intestinal  colic  is  referred  to  the  whole  abdomen;  that  of 
hepatic  colic  to  the  epigastric  zone,  and  that  of  renal  colic  to  the  lumbar 
region.  So  also  pain  in  the  heart,  lungs,  liver,  and  stomach  may  be  referred 
to  areas  innervated  by  the  cranial  nerves  and  nerves  given  off  from  the 


SYMPTOMS  AND  SIGNS:    PAIX.  583 

cervical  plexus,  and  the  pain  in  disease  of  the  pelvic  organs  is  very  com- 
monly referred  to  the  back.  A  striking  example  of  this  kind  of  pain-refer- 
ence is  seen  in  the  pain  and  exquisite  tenderness  of  the  right  hypochondrium 
sometimes  encountered  in  diaphragmatic  pleurisy. 

4.  Longitudinally  Related  Areas. — Pain  arising  in  the  course  of 
a  nerve  may  be  referred  to  its  terminal  distribution.  The  pain  in  the  stump, 
which  appears  to  be  in  the  amputated  foot,  is  a  familiar  example.  The 
lightning  pains  of  tabes,  the  thigh  pains  in  malignant  disease  of  the  rectum 
and  in  psoas  abscess,  and  the  pain  around  the  umbilicus  in  vertebral  caries 
are  further  illustrations.  Sometimes  the  areas  are  not  so  directly  related, 
as  in  the  knee  pain  in  hip-joint  disease,  the  shoulder  pain  in  disease  of  the 
liver,  and  the  pain  in  the  distribution  of  the  ulnar  nerve  in  angina  pectoris. 

Peripheral  pain  may  be  an  early  and  suggestive  symptom  in  organic 
disease  of  the  brain  and  spinal  cord.  In  meningitis  the  pains  in  the  back 
and  limbs  may  be  very  severe.  The  joints  are  frequently  the  seat  of  pain, 
which  may  be  more  or  less  constant  or  lancinating  and  paroxysmal. 

Painful  Crises. — Severe  and  prolonged  attacks  of  pain,  associated  with 
functional  disturbances  and  wholly  independent  of  local  organic  disease, 
occur  in  some  cases  of  locomotor  ataxia  and  are  known  as  the  tabetic  crises. 
They  are  (a)  cardiac — intense  precordial  pain  accompanied  by  a  feeling  of 
oppression  and  rapid  and  irregular  pulse;  (b)  gastric,  the  most  common — 
sudden  severe  pain  in  the  epigastrium,  with  vomiting,  rapid  and  irregular 
pulse,  sometimes  symptoms  of  collapse;  there  may  be  vomiting  without 
pain  or  pain  without  vomiting;  (c)  laryngeal,  which  is  comparatively 
rare — pain  in  the  larynx  with  paroxysmal  cough,  inspiratory  stridor  and 
sensations  of  choking;  (d)  pharyngeal,  also  rare — painful  acts  of  degluti- 
tion following  one  another  at  short  intervals  and  lasting  from  some  minutes 
to  half  an  hour.  Intestinal,  rectal,  urinary,  and  genital  crises  have  also 
been  described.  Suddenness  of  onset,  intensity,  paroxysmal  character, 
and  abrupt  termination  are  characteristic  of  these  attacks.  The  absence 
of  lesions  in  the  affected  viscera  either  during  the  attacks  or  in  the  intervals 
between  them  is  of  diagnostic  importance.    Errors  in  diagnosis  are  common. 

Localization  of  Pain. 

Superficial  pains  are  mostly  symptomatic  of  diseases  of  the  under- 
lying parts,  but  they  may  be  referred. 

Deep-seated  pain  attends  inflammatory  and  ulcerative  diseases  of 
the  viscera,  mediastinal  tumor,  aortic  aneurism,  visceral  cancer,  and  dis- 
ease of  the  bones. 

Pain  may  be  unilateral  or  bilateral.  The  former  usually  attends  mor- 
bid processes  confined  to  the  affected  Bide;  the  latter  those  involving  both 
sides  or  of  central  origin.  This  rule  is  far  from  being  absolute.  The  pain 
caused  by  floating  kidney  is  occasionally  referred  to  the  opposite  side  of 
t  he  abdomen. 

The  more  important  local  pain-  and  their  diagnostic  significance  are 
now  to  be  considered. 

Pain  in  the  Head.— (a)  Headache  is  a  term  used  to  designate  pain 
referred  to  various  regions  of  the  head.     It  may  be  paroxysmal  or  con- 


584  MEDICAL  DIAGNOSIS. 

tinuous.  The  term  cephalalgia  was  applied  by  the  ancients  to  slight, 
limited,  or  transitory  headaches;  the  term  cephalcea  to  severe,  deep-seated, 
and  chronic  pains  in  the  head.  Headache  is  in  many  cases  a  symptom  of 
such  importance  and  prominence  that  it  overshadows  all  others  and  lends 
to  the  clinical  picture  its  most  characteristic  feature,  often  at  first  sight  its 
only  obvious  feature.  Headache  is  a  symptom  very  often  significant 
when  other  phenomena  are  obscure.  It  thus  acquires  a  high  degree  of 
diagnostic  importance. 

Organic  and  Functional  Headaches. — Headaches  due  to  lesions  of 
the  skull  or  intracranial  disease  are  organic;  those  due  to  other  causes  are 
functional.  In  general  terms  headache  is  the  manifestation  of  the  irrita- 
tion of  sensory  nerve-fibres  caused  by  derangement  of  pressure  or  tension, 
inflammation,  toxaemia,  and  reflex  disturbances.  It  is  probable  that  the 
meninges  are  chiefly  concerned  in  the  causation  of  headache.  The  sub- 
stance of  the  brain  in  the  lower  animals  does  not  respond  to  direct  irrita- 
tion by  the  manifestations  of  pain;  and  lesions  of  cerebral  tissue  not  directly 
or  indirectly  involving  the  membranes  may  exist  without  causing  headache. 
The  meninges  and  especially  the  dura,  on  the  other  hand,  are  directly  or 
indirectly  implicated  in  those  pathological  processes  which  give  rise  to 
headache.  The  sensory  nerve  supply  of  the  dura  in  the  anterior  three- 
fourths  of  its  extent,  that  of  the  falx  and  probably  that  of  the  tentorium 
are  derived  from  the  trigeminus,  while  the  dura  mater  of  the  posterior  fossa 
is  supplied  with  sensory  fibres  from  the  vagus.  The  trigeminus  is  the  nerve 
of  sensation  to  the  scalp  as  far  back  as  the  vertex,  while  the  posterior 
branches  of  the  upper  four  cervical  nerves  supply  the  muscles  and  the  skin 
of  the  back  of  the  neck  and  the  occiput.  Sometimes  headache  is  referred 
to  the  scalp;  usually  the  pain  is  deep-seated  and  intracranial.  In  rare 
cases  superficial  headaches  are  essentially  myalgic,  the  pathological  condi- 
tion involving  the  occipitofrontal,  temporal,  or  sternomastoid  muscles. 

The  following  clinical  considerations  in  regard  to  headache  are 
important: 

Distribution  of  Headache. — This  pain  is  usually  bilateral.  It  may 
be  frontal,  occipital,  parietal,  and  temporal,  vertical  or  diffuse.  The  area 
most  commonly  involved  is  frontal,  next  in  order  of  frequency  is  diffuse 
headache,  then  follow  in  the  order  named  vertical,  occipital,  and  temporal. 
Headache  often  shifts  from  one  part  of  the  head  to  another  and  is  not 
always  confined  to  regions  limited  by  anatomical  boundaries. 

Varieties  of  Headache. — Headache,  according  to  the  character  of  the 
pain,  may  be:  1.  Pulsating  or  throbbing.  Headache  of  this  kind  is  symp- 
tomatic of  circulatory  disturbances;  it  is  often  diffuse.  2.  Dull,  heavy. 
This  is  the  headache  due  to  toxaemia;  it  is  usually  frontal,  sometimes 
occipital.  3.  Binding  or  constrictive;  the  sensation  is  often  described  as 
that  of  a  tight  band  around  the  head;  the  focus  of  intensity  is  referred  to 
the  parietal  regions.  This  is  the  headache  of  hysteria  and  neurasthenia. 
4.  Burning  or  sore;  forms  of  headache  diagnostic  of  anaemia,  rheumatism, 
and  lithaemia.  5.  Boring  or  sharp.  These  headaches  are  symptomatic  of 
hysteria  and  allied  conditions;  they  are  usually  localized;  one  form  is 
known  as  "clavus" — the  sensation  as  if  a  nail  were  being  driven  into 
the  head. 


SYMPTOMS  AND  SIGNS:    PAIN.  585 

Headache  may  be  transient  or  persistent.  In  the  latter  case  there  may 
be  exacerbations  and  remissions,  or  occasional  intermissions  which  may 
last  for  days  or  weeks.  There  may  be  slight,  continuous  headache  with 
exacerbations  of  varying  intensity.  Headache  of  this  kind  is  symptomatic 
of  forms  of  reflex  irritation,  especially  those  arising  from  defects  of  accom- 
'modation.  Persistency  is  characteristic  of  organic  headaches  such  as  occur 
in  cerebral  tumor  or  abscess  or  pachymeningitis,  or  those  which  result  from 
excesses  in  tobacco  or  alcohol,  syphilis,  and  uraemia.  The  headaches  which 
occur  after  sunstroke  are  persistent,  with  brief  and  irregular  periods  of 
remission. 

The  headache  following  cerebral  concussion  is  severe  and  protracted. 
It  may  be  circumscribed  and  limited  to  a  region  corresponding  to  the  seat 
of  the  injury  or  to  the  opposite  side  of  the  head.  It  is  commonly  associated 
with  tenderness  on  light  percussion.  The  headache  following  injur}''  may 
be,  on  the  other  hand,  diffuse.  It  is  apt  to  be  associated  with  vertigo, 
lassitude,  and  indisposition  to  mental  effort. 

Significance  of  Headache.  —  Congestion.  —  Headache  may  result 
from  mechanical  interference  with  the  return  of  venous  blood  from  the 
head.  When  produced  by  improper  clothing  it  is  slight  and  ceases  upon 
removal  of  the  cause;  when  due  to  venous  obstruction  from  the  pressure  of 
tumors  it  is  not  usually  severe.  The  headache  caused  by  violent  paroxysmal 
or  frequently  repeated  cough  is  congestive. 

Hypercemia. — Headache  is  symptomatic  of  active  cerebral  hyperaemia 
such  as  follows  excessive  and  prolonged  mental  effort,  and  results  from  the 
action  of  vasodilator  drugs,  as  alcohol  and  the  nitrites.  This  form  of 
headache  occurs  in  the  initial  stage  of  acute  meningitis.  The  headache  of 
cerebral  hyperaemia,  whether  passive  or  active,  is  usually  frontal  or  diffuse, 
often  pulsating  or  throbbing. 

Ancrmia. —  Headache  occurs  in  the  anaunia  due  to  blood  loss  or  other 
cause.  It  is  a  common  symptom  in  chlorosis.  Anaemic  headache  is  com- 
monly severe,  usually  frontal  or  diffuse,  often  attended  by  sensations  of 
pressure  and  not  rarely  associated  with  vertigo  and  tinnitus  aurium.  The 
headache  of  anaemia  is  intensified  by  effort. 

Inflammation. — Headache  is  characteristic  of  all  forms  of  cerebral 
meningitis,  both  acute  and  chronic.  It  is  usually  at  first  localized,  a  fact 
of  importance  in  the  diagnosis  of  meningitis  due  to  mastoid  or  ethmoid 
disease  or  disease  or  injury  of  the  cranial  bones.  It,  however,  rapidly 
becomes  diffuse.  Meningeal  headache  is  usually  continuous  with  exacer- 
bations of  great  severity.  Headache  in  exceptional  cases  is  absent  in 
the  early  stages  of  gradually  developing  leptomeningitis.  Sudden  intense 
headache  with  painful  rigidity  of  the  muscles  of  the  back  of  the  neck  and 
vomiting  are  early  symptoms  of  epidemic  cerebrospinal  fever.  Intense 
paroxysmal  headache  is  a  symptom  of  tuberculous  meningitis.  The  head- 
ache of  pachymeningitis  is  local  at  first,  but  later  becomes  generalized. 
Severe  frontal  headache,  usually  unilateral,  is  symptomatic  of  disease  of 
the  frontal  sinuses. 

Infection.-  Headache  is  a  common  manifestation  of  infection.  This 
headache  i-  usually  frontal,  it  may  be  occipital  <>r  general,  is  often  neuralgic 
or  superficial,  BOOli   becoming  dull,  deep-seated,  and  severe.     Headache  is 


586  MEDICAL  DIAGNOSIS. 

an  important  symptom  of  the  stage  of  onset  of  the  acute  febrile  infections. 
It  is  early  and  severe  in  typhus  and  associated  with  pain  in  the  back  and 
limbs.  After  a  time  it  is  followed  by  stupor.  It  is  a  constant  symptom  in 
the  early  stages  of  enteric  fever  but  subsides  spontaneously  during  the 
second  week  of  the  disease.  It  occurs  at  the  onset  of  relapsing  fever  and 
persists  until  the  crisis,  when  it  commonly  ceases  altogether.  The  head- 
ache of  influenza  is  diffuse  with  points  of  intensity  in  the  region  of  the 
frontal  sinuses  and  behind  the  eyeballs.  It  may  be  a  troublesome  sequel. 
Intense  headache  characterizes  the  period  of  invasion  of  smallpox  and 
is  usually  accompanied  by  excruciating  pains  in  the  back  and  joints. 

Headache  occurs  in  early  syphilis.  The  headaches  of  late  syphilis  are 
usually  symptomatic  of  arterial  changes,  gummata,  or  meningitis.  Head- 
ache is  common  in  hereditary  syphilis.  Paroxysmal  headache  is  symp- 
tomatic of  malaria.  It  occurs  in  the  hot  stage  of  the  paroxysm.  It  is 
persistent  and  intense  in  estivo-autumnal  fever.  Periodical  headache  may 
be  the  chief  symptom  in  estivo-autumnal  infection. 

Toxccmia. — Some  intractable  headaches  are  symptomatic  of  chronic 
uraemia.  They  are  frontal  or  temporal,  intense,  usually  continuous,  with 
irregular  exacerbations.  Headaches  of  the  same  general  character  occur  in 
diabetes  and  in  those  suffering  from  the  gouty  diathesis.  To  this  group  we 
may  refer  the  headaches  of  chronic  lead  poisoning,  those  occurring  in  gastro- 
hepatic  derangements,  and  constipation.  These  headaches  are  intensified 
by  alcoholic  beverages  and  relieved  by  free  purgation.  Certain  drugs  cause 
headache.  Full  doses  of  quinine  or  the  salicylates  produce  headache  and 
tinnitus  aurium.  Opium  causes  distressing  headache  with  floating  sensa- 
tions, nausea,  and  vomiting.  All  these  symptoms  are  increased  when  the 
patient  assumes  the  upright  posture.  Tense,  vertiginous  headache  follows 
the  administration  of  the  nitrites  in  full  doses.  Headache  is  a  significant 
symptom  in  chronic  poisoning  by  lead,  tobacco,  alcohol,  opium,  and  chloral. 
In  the  case  of  lead  and  of  alcohol  arterio-capillary  sclerosis  is  cooperative. 
Opium  and  chloral  headaches  are  often  abstinence  symptoms,  occurring  upon 
the  withdrawal  of  the  drug.  Intense  headache  not  unlike  that  of  migraine 
frequently  follows  excesses  in  alcohol — the  acute  alcoholism  of  debauch. 

Cerebral  Abscess. — Headache  is  often  very  severe  and  persistent  in 
cerebral  abscess.  It  is  ap't  to  be  associated  with  vertigo  and  pronounced 
mental  dulness  and  irritation.  Vomiting  is  common  but  not  constant. 
Chronic  brain  abscess  may  present  no  other  symptom  than  headache,  vertigo, 
mental  dulness,  irritability,  and  physical  depression.  The  pain  is  usually 
related  to  the  region  of  the  lesion;  in  ear  disease  it  is  referred  to  the  parietal 
or  the  occipital  region  of  the  affected  side.  In  abscess  following  disease  of 
the  nasal  or  ethmoid  bones  the  pain  is  referred  to  the  brow.  In  abscess 
from  traumatism  the  focus  of  pain  is  located  in  the  region  of  the  injury. 

Tumor. — Headache  may  be  said  to  be  a  constant  symptom  of  brain 
tumor.  Its  frequency  and  intensity  vary  according  to  the  location  of  the 
new  growth,  the  rapidity  of  its  development,  and  in  some  degree  to  its 
character.  Headache  is  more  persistent  and  severe  in  cerebellar  than  in 
cerebral  tumors;  in  those  of  the  cerebral  hemispheres  than  in  those  of  the 
base  and  in  those  directly  implicating  the  meninges.  It  is  more  prominent 
in  tumors  of  rapid  than  in  those  of  slow  growth,  without  regard  to  the  nature 


SYMPTOMS  AND  SIGNS:    PAIN.  587 

of  the  pathological  process.  In  general  terms  the  nature  of  the  tumor 
formation  has  no  direct  relation  to  the  intensity  of  the  headache,  the 
exception  to  this  rule  being  that  gliomata  are  less  painful  than  other  forms 
of  coarse  intracranial  new  growths.  Headache  in  brain  tumor  is  sometimes 
dull  and  boring,  sometimes  lancinating,  usually  intense,  often  agonizing. 
It  is  commonly  continuous  with  periods  of  intensification,  but  sometimes 
recurs  with  a  regular  periodicity  suggestive  of  malaria.  The  fact  that  it  is 
commonly  worse  at  night  has  some  diagnostic  value.  The  focus  of  the 
headache  in  cerebral  tumor  may  be  in  the  region  involved,  in  the  brow  or 
in  the  occiput,  or  the  pain  may  be  diffuse.  The  headache  of  brain  tumor 
may  be  localized  when  of  moderate  degree,  diffuse  during  periods  of  inten- 
sification. Light  percussion  with  the  finger-tips  may  elicit  tenderness  in 
a  region  corresponding  to  the  tumor.  The  headache  of  pachymeningitis 
interna  hemorrhagica  is  usually  at  first  referred  to  the  vertex;  later  it 
becomes  generalized. 

Aneurism. — Headache,  either  continuous  or  paroxysmal,  is  the  most 
common  symptom  of  intracranial  aneurism  affecting  the  larger  arteries 
at  the  base.  The  location  of  the  headache  has  in  general  no  definite 
relation  to  the  position  of  the  aneurism,  though  aneurisms  of  the  basilar 
artery  usually  occasion  occipital  headache.  Headache  occurs  in  caries 
of  the  bones  of  the  skull. 

Neurotic  States. — Headache  is  a  very  common  symptom  in  neuro- 
pathic conditions.  In  neurasthenia  it  is  frontal,  occipital,  or  diffuse;  it  is 
apt  to  be  continuous  and  is  aggravated  by  mental  application  and  physical 
effort.  Its  intensity  is  moderate  and  it  is  attended  by  sensations  of  pres- 
sure in  the  head,  aching  in  the  back  of  the  neck,  and  spinal  pains.  Head- 
ache is  very  common  in  the  interparoxysmal  periods  of  hysteria.  It  is 
often  referred  to  the  vertex  and  may  be  severe  and  persistent.  Headache 
is  common  in  emotional  and  precocious  children.  It  is  frequently  associated 
with  brow  pains,  pains  in  the  back  of  the  neck,  and  intolerance  of  bright 
light.  Headaches  of  this  kind  are  allied  to  the  headaches  of  hysteria. 
Headache  frequently  enters  into  the  symptom-complex  of  the  epileptic 
paroxysm.  It  may  precede  or  follow  the  convulsive  attack.  In  the  latter 
case  it  is  associated  with  drowsiness  and  hebetude.  Headache  is  common 
in  petit  mal.  In  many  cases  of  epilepsy  it  constitutes  an  important  symp- 
tom in  the  interparoxysmal  state. 

Reflex  Headache. — This  form  is  often  troublesome  and  persistent. 
This  is  sometimes  the  case  when  the  direct  symptoms  of  the  local  disease 
are  slight  or  absent.  Errors  of  refraction  constitute  a  common  cause  of 
reflex  headache.  The  pain  is  usually  frontal,  sometimes  temporal,  often 
occipital.  The  patient  i>  frequently  unaware  of  any  defect  in  visual  accom- 
modation.  The  headache  is  usually  aggravated  by  close  or  prolonged 
use  of  the  eyes.  Reflex  headache  may  occur  as  a  symptom  in  chronic  nasal 
disease  especially  in  affections  of  the  accessory  sinuses.  It  usually  involves 
the  temporal  region  or  the  vertex.  It  is  associated  with  sensitiveness  of 
the  nasal  wall  of  the  orbit  and  hypersesl het ic  areas  on  the  mucous  mem- 
brane <>f  the  middle  turbinate  bone.  Headache  is  an  important  symptom 
of  adenoid   vegetations  in   the  nasopharynx.     It   constitutes  one  of  the 

forms   included    under  such   terms  as  "school    headaches,"   "headaches  of 


588  MEDICAL  DIAGNOSIS. 

the  period  of  growth,"  and  the  like.  Associated  symptoms  are  mouth- 
breathing,  mental  dulness,  and  irritability.  Carious  teeth  and  exposure 
of  the  pulp  not  only  cause  toothache  but  occasionally  also  cause  reflex 
headache.  Disease  of  the  auditory  apparatus  may  be  the  unsuspected 
cause  of  persistent  headache. 

The  headache  of  acute  indigestion  and  gastro-intestinal  catarrh  is 
probably  rather  toxaemic  than  reflex. 

The  importance  of  headache  as  a  manifestation  of  disease  of  the  sexual 
organs  is  probably  over-estimated;  yet  this  symptom  is  very  common  in 
those  of  both  sexes  who  suffer  from  actual  disease  of  the  reproductive 
apparatus  or  are  the  victims  of  psychical  processes  concerning  such  diseases. 
Very  often  these  headaches  are  due  rather  to  the  attendant  neuropathic 
condition  than  to  reflex  irritation. 

Associated  Symptoms. — Vertigo,  nausea,  vomiting,  drowsiness,  irrita- 
bility, and  hebetude  are  associated  with  headache  with  such  frequency  as 
to  indicate  a  common  causation.  These  symptoms  are  as  a  rule  less  con- 
stant and  less  severe  in  symptomatic  than  in  organic  headaches.  Vertigo 
is  a  frequent  attendant  upon  headache  due  to  gastro-intestinal  disorder; 
nausea  and  vomiting  in  acute  toxaemia;  somnolence  in  malaria,  anaemia, 
and  syphilis.  In  organic  headaches  the  presence  of  this  group  of  symptoms 
and  their  persistence  are  important  and  suggestive. 

Headache  is  essentially  a  symptom  and  a  careful  examination  and 
inquiry  will  reveal  some  general  or  local  cause.  Headache  is  to  be  differen- 
tiated from   migraine — a  paroxysmal  neurosis. 

Neuralgia  differs  from  headache  in  the  following  points:  The  pain 
involves  the  trunk  or  branches  of  the  nerve  rather  than  its  peripheral 
distribution.  It  is  unilateral,  localized,  sharp,  paroxysmal,  and  there  are 
present  the  characteristic  tender  points  of  Valleix.  Neuralgia  affecting 
the  first  branch  of  the  fifth  nerve  is  sometimes  attended  with  suffusion  of 
the  eye  and  oedema  of  the  lids. 

Functional  and  Organic  Headaches. — The  differential  diagnosis 
between  functional  and  organic  headaches  is  of  fundamental  importance. 
Organic  headache  is  commonly  persistent,  varying  from  time  to  time  in 
intensity,  sometimes  undergoing  violent  exacerbations  but  rarely  wholly 
absent.  It  often  interferes  with  sleep.  It  is  aggravated  by  mental  or 
physical  effort,  by  excitement,  alcohol,  and  all  conditions  that  increase 
intracranial  hyperaemia.  It  yields  less  readily  than  functional  headache 
to  symptomatic  treatment.  It  tends  to  progressively  increase  in  severity 
and  is  in  many  cases  ultimately  replaced  by  the  stupor,  drowsiness  or  coma 
of  the  terminal  stage  of  the  disease.  Associated  symptoms,  such  as  vomit- 
ing, vertigo,  hebetude,  and  irritability,  are  of  diagnostic  importance,  and 
double  optic  neuritis,  convulsions,  and  localizing  symptoms,  as  monospasm, 
cranial  nerve  paralysis,  cerebellar  titubation,  forced  movement,  and  hemi- 
anopsia, render  the  differential  diagnosis  between  organic  headaches  and 
functional  headaches  in  most  cases  an  easy  matter. 

(b)  Pains  in  the  Scalp. — Myalgic  pains  have  been  already  spoken  of. 
They  are  usually  frontal  or  occipital,  increased  by  voluntary  movements 
of  the  scalp  and  by  pressure.  Various  affections  of  the  skin  are  attended 
by  itching  and  burning  pains  of  moderate  degree.    Local  dermatitis  attended 


SYMPTOMS  AND  SIGNS:    PAIN.  589 

with  pain  sometimes  results  from  the  injudicious  application  of  hair  washes 
containing  excess  of  cantharides  and  sometimes  from  the  action  of  pediculi; 
also  from  burns  and  scalds,  from  erysipelas,  and  from  traumatism. 

Diffuse  wandering  pains  are  often  experienced  in  various  parts  of  the 
scalp  and  are  associated  with  tenderness  of  the  skin.  These  pains  are  not 
confined  to  the  ramification  of  nerve-trunks  and  cannot  be  strictly  regarded 
as  neuralgic,  but  they  very  frequently  alternate  with  true  neuralgia.  A 
patient  under  my  observation  compared  these  pains  to  sheet  lightning. 

(c)  Pains  in  the  Face. — The  most  important  is  trigeminal  or  facial 
neuralgia,  known  also  as  tic  douloureux  and  prosopalgia.  Neuralgia  of  the 
fifth  nerve  is  much  more  frequent  than  all  other  forms  of  neuralgia. 
The  pain  is  spontaneous,  paroxysmal,  and  unilateral.  Neuralgic  pains  in- 
volving the  ophthalmic  division  usually  affect  the  supra-orbital  branch 
and  are  known  as  brow  ague  or  supra-orbital  neuralgia.  The  pain 
radiates  over  the  front  of  the  head  from  the  supra-orbital  notch.  It  may 
be  felt  in  the  eyelid  or  the  eyeball  or  at  the  side  of  the  nose.  Tender 
points  are  found  at  or  above  the  supra-orbital  notch,  in  the  upper  eyelid, 
and  on  the  side  of  the  nose. 

The  neuralgic  pain  may  be  referred  to  the  eyeball  itself.  It  may  occur 
spontaneously  or  as  the  result  of  over-use  of  the  eyes.  It  is  attended  with 
dimness  of  vision  and  lachrymation  and  may  occur  alone  or  in  connection 
with  other  neuralgic  pain  in  the  region  of  the  fifth. 

Neuralgia  of  the  superior  maxillary  division  of  the  fifth  nerve  is  referred 
to  the  region  between  the  orbit  and  the  mouth  and  the  side  of  the  nose. 
Areas  of  special  intensity  are  upon  the  side  of  the  nose,  over  the  prominent 
part  of  the  upper  jaw  and  along  the  gum.  Paroxysms  are  frequently  induced 
by  the  use  of  the  tooth-brush.  When  the  inferior  maxillary  division  is 
involved  a  focus  of  pain  is  frequently  found  just  in  front  of  the  ear,  or  in 
the  temple  or  opposite  the  point  of  emergence  of  the  nerve  from  the  fora- 
men, or  in  the  region  of  the  parietal  eminence,  and  sometimes  a  point  at 
the  side  of  the  tongue. 

In  intense  paroxysms  of  trifacial  neuralgia  the  whole  side  of  the  face 
and  brow  is  involved  and  there  is  reflex  facial  spasm — tic  convulsif.  Supra- 
orbital neuralgias  are  occasionally  attended  with  vasomotor  disturbance. 
In  other  instances  a  herpetic  eruption  occurs  which  is  probably  the  mani- 
festation of  an  actual  neuritis.  Intractable  neuralgias  of  the  fifth  nerve 
occurring  late  in  life  are  known  as  degenerative  neuralgias  and  are  asso- 
ciated with  changes  in  the  ganglion  of  Gassei*. 

Severe  pains  in  the  distribution  of  the  fifth  nerve  accompany  cancer  of 
the  tongue,  lingua]  ulcer,  and  caries  of  the  inferior  maxilla.  Caries  of  the 
teeth  and  exposure  of  the  pulp  may  give  rise  to  pain  referred  to  the  car. 

(d)  Pain  in  the  Eye.  -Inflammatory  diseases  of  the  eye  causelocal  pain. 
In  acute  conjunctivitis  there  is  pain  in  the  eyelids,  accompanied  by  photo- 
phobia and  lachrymation;  in  iritis  pain  in  the  eyeball  and  intense  supra- 
orbital pain,  which  may  radiate  in  the  distribution  of  the  ophthalmic  division. 

The  pain  of  glaucoma  involves  the  distribution  of  the  trigeminus, 
having  its  focus  of  intensity  in  the  eyeball  or  at  the  supra-orbital  notch. 
In  the  acute  cases  it  is  agonizing  and  associated  with  depression,  pallor, 
nausea,  and  vomiting.     In  the  chronic  form  it  may  be  subacute  with  par- 


590  MEDICAL  DIAGNOSIS. 

oxysms  of  great  severity.  As  the  disease  begins  with  great  frequency  on 
one  side  there  is  a  misleading  resemblance  to  migraine.  Increase  of  the  intra- 
ocular tension,  irregular  or  dilated  pupil,  with  inactive  iris,  haziness,  anaesthe- 
sia of  the  cornea,  and  various  visual  derangements  are  suggestive  symptoms. 

(e)  Pain  in  the  Ear. — The  pain  of  acute  middle-ear  disease  is  intense, 
throbbing,  increased  by  pressure  in  front  of  the  tragus  and  by  gentle  trac- 
tion of  the  ear.  It  is  subject  to  exacerbations  and  remissions  and  often 
radiates  to  the  side  of  the  face.  Upon  spontaneous  or  surgical  perforation 
of  the  tympanic  membrane  the  distressing  feeling  of  tension  is  followed  by 
immediate  relief.  Tinnitus  is  a  common  accompaniment.  Pain  referred 
to  the  ear  and  the  side  of  the  head  is  a  prominent  s3rmptom  in  mastoid  dis- 
ease.   It  is  accompanied  by  tenderness  upon  pressure  and  localized  oedema. 

(f)  Pain  Referred  to  the  Mouth. — Pain  is  a  symptom  of  various  forms 
of  stomatitis.  It  is  intense  in  aphthous  stomatitis,  a  very  trifling  affection, 
and  often  wholly  absent  in  cancrum  oris,  one  of  the  gravest  of  diseases. 
In  mucous  patches  and  syphilitic  ulceration  pain  is  less  conspicuous  than 
in  tuberculous  ulceration.  In  carcinomata  pain  is  a  persistent  and  distress- 
ing symptom.  In  inflammatory  and  ulcerative  conditions  of  the  pharynx 
pain  is  a  prominent  symptom.  It  is  excited  by  mechanical  irritation  and 
by  the  contraction  of  the  pharyngeal  muscles  in  deglutition.  Pain  is  not 
a  prominent  symptom  in  epidemic  parotitis  and  parotid  bubo.  It  is  excited, 
however,  by  the  movements  of  the  parts  involved  and  accompanied  by 
great  tenderness  upon  pressure. 

(g)  Sinus  Pain. — Pain  is  a  prominent  symptom  in  disease  of  the  acces- 
sory sinuses  of  the  nose,  especially  in  those  cases  in  which  there  is  an  obstruc- 
tion to  the  outlet.  Under  these  circumstances  the  pain  may  be  extremely 
severe  and  accompanied  by  marked  systemic  disturbance,  as  fever,  chilli- 
ness, headache,  and  malaise.  The  sinuses  usually  involved  are  the  antrum 
of  Highmore  and  the  frontal  sinuses.  Free  discharge  of  mucus  or  pus  is 
usually  followed  by  immediate  relief,  but  there  are  chronic  forms  in  which 
the  pain  is  apt  to  be  of  a  dull  character  and  constant,  with  exacerbations 
in  damp  weather  and  after  exposure  to  cold.  The  diagnosis  of  antrum 
disease  may  be  confirmed  by  transillumination  with  an  electric  light. 

Pain  in  the  Body. — (a)  Pain  in  the  Back— Backache;  Rhachialgia. — 
Pain  may  occur  in  any  part  of  the  back.  It  is  more  common  in  the 
lumbar  and  sacral  regions  than  elsewhere.  Pain  in  the  back  of  the  neck 
extending  between  the  shoulder-blades  is  a  common  symptom  in  neuras- 
thenia and  hysteria. 

Acute  pain  in  the  small  of  the  back  attends  the  period  of  onset  of  many 
of  the  infectious  febrile  diseases,  especially  influenza,  dengue,  variola,  and 
cerebrospinal  fever.  It  occurs  also  in  angina  tonsillaris  and  acute  nephritis. 
Acute  pain  in  the  back,  much  aggravated  upon  movements  of  extension, 
as  in  rising  after  lacing  one's  shoes,  is  characteristic  of  lumbago.  Unilateral, 
deep-seated  lumbar  pain  of  great  severity  is  symptomatic  of  renal  colic. 
Persistent  pain  of  this  kind  attends  renal  calculus.  This  pain  is  aggravated 
by  pressure  over  the  kidney  or  sudden  jarring  of  the  body.  Pain  in  the  back 
is  often  present  in  floating  kidney.  Sacral  pains  are  symptomatic  of  disease 
of  the  pelvic  organs,  especially  uterine  flexions  and  displacements,  ovarian 
disease,  disease  of  the  colon  and  rectum,  hemorrhoids,  and  urethral  stric- 


SYMPTOMS  AND  SIGNS:    PA]  V.  591 

ture.  Many  of  the  pains  in  the  lower  part  of  the  back  are  myalgic.  Pains 
of  this  kind  result  from  occasional  or  habitual  overwork  of  the  muscles  or 
from  traumatism  in  the  form  of  contusion  or  strain,  or  finally  from  expos- 
ure to  cold  or  damp,  especially  in  lithaemic  individuals.  The  pain  of  myalgia 
is  increased  by  movement,  cold,  and  pressure;  it  is  relieved  by  rest  in  the 
recumbent  posture  and  by  hot  applications. 

Pain  in  the  spine  occurs  in  disease  of  the  vertebrae.  Traumatism, 
syphilis,  tuberculosis,  and  caries  from  pressure,  as  in  aneurism  of  the  aorta, 
are  common  causes.  The  pain  is  local  and  corresponds  to  the  segment  of 
the  column  involved.  It  is  increased  by  sudden  pressure  upon  the  head 
or  shoulders,  by  jarring,  by  the  application  of  heat,  cold,  and  faradism,  and 
is  relieved  by  the  recumbent  posture  and  in  some  cases  by  suspension  and 
a  properly  applied  spinal  jacket.  Rigidity  results  from  muscular  spasm  in 
the  earlier  stages  and  from  ankylosis  in  the  later.  Various  deformities 
occur.  Pain  is  present  in  that  form  of  arthritis  deformans  which  involves 
the  vertebrae — spondylitis  deformans — spondylose  rhizomelique.  There  are 
associated  nerve-root  symptoms,  as  anaesthesia  and  muscular  atrophy. 

Pain  attends  various  diseases  of  the  spinal  meninges.  It  is  local  and 
often  intense.  There  are  symptoms  of  irritation  in  the  course  of  the  nerves. 
The  more  common  causes  are  hemorrhage  into  the  spinal  membranes  and 
meningitis.     Muscular  spasm  and  rigidity  are  present. 

Diseases  of  the  cord  are  more  apt  to  cause  radiating  and  referred  pains 
than  pain  in  the  spine  itself.  The  latter  is  felt  in  the  lumbar  region;  the 
former,  as  nerve-root  irritation,  as  girdle  pains,  and  in  the  lightning  pains 
of  tabes. 

(b)  Pain  in  the  Side. — 1.  The  pain  may  be  symptomatic  of  injury 
or  inflammation  of  the  skin,  as  abrasion,  contusion,  local  dermatitis,  or 
furunculosis.  The  last  is  common  in  the  axillary  region.  In  rare  instances 
phlegmon  or  subcutaneous  extravasations  of  blood  may  be  the  cause  of 
severe  pain.    An  inspection  of  the  parts  is  necessary  in  all  cases. 

2.  Myalgic  pains  are  not  uncommon.  Pleurodynia  affects  the  muscles 
on  one  side,  usually  the  intercostals,  sometimes  the  pectorals  and  the 
serratus  magnus.  It  is  more  common  on  the  left  than  on  the  right  side. 
It  is  especially  distressing  since  the  muscles  are  in  constant  use  in  respira- 
tion. The  movements  are  restricted  on  the  affected  side,  but  deep  breath- 
ing, coughing,  and  forced  lateral  movements  increase  the  pain.  Tenderness 
is  present  often  in  a  limited  area.  This  affection  may  suggest  intercostal 
neuralgia,  from  which  it  is  to  be  distinguished  by  the  more  circumscribed 
area  involved,  the  paroxysmal  character  of  neuralgic  pain,  and  the  well- 
defined  tender  points.  It  is  sometimes  mistaken  for  pleurisy,  but  the 
absence  of  friction  sounds  i-  of  diagnostic  importance.  Violent  spasmodic 
flexion  to  one  side  is  an  occasional  though  rare  manifestation  of  tetanus 
arnl  is  attended  with  great  pain  in  the  affected  muscles.  Side  pains  refer- 
able to  the  muscles  are  observed  in  some  cases  of  trichiniasis. 

3.  Pains  due  to  injury  or  disease  of  the  bones  may  be  referred  to  the 
side.  Fracture  of  the  ribs,  periostitis,  osteosarcoma,  rickets,  and  some  cases 
ot  osteitis  deformans  are  to  be  considered.  The  diagnosis  demands  a  care- 
ful examination  of  the  area  involved  by  inspection,  palpation,  ausculta- 
tion, and  in  obscure  cases  by  the  Rontgen  rays. 


592  MEDICAL  DIAGNOSIS. 

4.  The  pain  of  plastic  pleurisy  is  referred  to  the  inframammary 
region  or  the  side.  It  is  sharp  or  stabbing, — the  stitch  in  the  side, — 
increased  on  deep  breathing  and  accompanied  by  friction  sounds,  in  some 
cases  friction  fremitus  and  a  dry  cough.  It  may  occur  in  previously 
healthy  individuals,  or  be  accompanied  by  slight  fever  and  presently  dis- 
appear; it  is  a  secondary  process  in  croupous  pneumonia  and  develops 
during  cancer,  abscess,  and  gangrene  when  the  surface  of  the  lung  is 
involved.  It  is  a  very  common  phenomenon  in  tuberculosis  of  the  lungs 
and  may  be  basic  or  apical. 

5.  Pain  in  the  side  may  be  due  to  visceral  disease.  Sudden  tension  of 
the  spleen,  as  often  occurs  in  boys  after  running,  is  accompanied  by  intense 
pain  in  the  infra-axillary  region  of  the  left  side.  Heavy,  dull,  dragging 
pains  are  symptomatic  of  the  splenic  tumor  of  leukaemia  and  the  malarial 
cachexia — ague  cake.  Renal  colic  is  characterized  by  an  extension  of  the 
pain  from  the  lumbar  region  to  the  affected  side  and  thence  downward 
toward  the  groin.  In  biliary  colic  the  pain  frequently  extends  to  the  right 
side  of  the  chest.  A  dull  heavy  pain  in  the  side  sometimes  attends  up- 
ward pressure  upon  the  diaphragm  such  as  occurs  in  an  overloaded  stom- 
ach or  distended  colon,  rapidly  developing  ascites,  or  an  enormous  abdom- 
inal tumor.  Pain,  paroxysmal  in  character  but  not  extremely  intense, 
occurs  in  the  early  stage  of  some  cases  of  pyelitis.  Intense  pain  in  the 
lumbar  region,  aggravated  by  pressure,  is  a  symptom  of  perinephritic 
abscess.  It  is  often  referred  to  the  hip-joint  or  the  adjacent  region  or  the 
inner  aspect  of  the  thigh.  This  pain  is  attended  with  fixation  of  the  thigh, 
which  is  flexed  to  relax  the  psoas  muscle,  and  the  patient  in  walking  stoops 
and  throws  his  weight  upon  the  sound  side.  The  pain  of  hepatic  abscess 
is  usually  referred  to  the  back  or  shoulders;  it  may  be  most  severe  in  the 
right  hypochondrium.  A  duller,  dragging  pain  is  felt  in  the  right  side  when 
the  patient  turns  upon  the  left.  The  pain  of  angina  pectoris  is  occasionally 
referred  to  the  left  side — fifth,  sixth  and  seventh  and  even  eighth  and  ninth 
dorsal  areas. 

6.  Pain  in  the  side  is  very  often  the  manifestation  of  disease  of  the 
nerves  themselves.  Neuralgia  may  be  the  result  of  nutritional  changes  in 
the  sensory  nerve-roots,  the  course  of  the  nerve,  or  its  peripheral  distribu- 
tion. Intercostal  neuralgia  is  very  common.  Women  are  more  liable  than 
men;  adults  far  more  liable  than  children.  The  left  side  is  more  frequently 
involved  than  the  right.  Neuropathic  individuals  especially  suffer.  Inter- 
costal neuralgia  is  encountered  in  anaemic  conditions,  general  malnutrition, 
gout,  lead  poisoning,  malaria,  cachexia,  and  chronic  nephritis.  The  attack 
may  follow  exposure  to  cold.  The  pain  is  paroxysmal  and  burning  or 
lancinating  and  there  are  characteristic  points  douloureux.  Trophic  or 
vasomotor  phenomena  may  occur,  as  local  oedema  or  erythema.  The 
posterior  branches  of  the  lumbar  plexus  may  be  involved  with  pain  in 
advance  of  the  crest  of  the  ilium  extending  along  the  inguinal  canal  and 
spermatic  cord  to  the  scrotum — irritable  testis — or  the  labium  majus. 
The  pain  of  herpes  zoster  is  intense  and  often  persistent.  It  corresponds 
to  the  distribution  of  the  eruption.  The  pain  in  caries  of  the  vertebrae 
and  aneurism  of  the  descending  aorta  is  referred  to  the  distribution  of  the 
intercostal  nerves. 


SYMPTOMS  AND  SIGNS:   PAIN.  593 

(c)  Pain  in  the  Chest  and  Abdomen. — 1.  The  skin  may  be  the  seat 
of  pain  in  inflammatory  diseases,  burns,  severe  eruptions,  and  herpes  zoster. 
Painful  burns  sometimes  result  from  the  unguarded  use  of  sinapisms  or 
hot-water  bags.     An  inspection  of  the  part  is  necessary. 

2.  Myalgia  of  the  abdominal  muscles  may  result  from  continuous 
cough.  The  epigastric  pain  in  children  suffering  from  measles  is  due  to  the 
cough.  Muscular  pain  attends  tetanus  and  some  cases  of  strychnia  poison- 
ing.    Trichiniasis  is  to  be  considered. 

3.  Periostitis  and  necrosis  of  the  sternum,  costal  cartilages,  and  ribs 
cause  pain  in  the  anterior  wall  of  the  thorax.  Resorption  and  ulceration 
from  aneurism,  malignant  disease,  syphilis,  and  enteric  fever  are  common 
causes  of  painful  lesions  in  these  structures.  Contusions,  fractures,  and 
dislocations  cause  pain. 

4.  Many  visceral  diseases  cause  pain  in  the  chest  and  abdomen.  It  is 
an  important  sign  of  aneurism  of  the  aorta.  It  is  usually  dull  and  persistent 
with  frequent  paroxysms  in  which  it  is  sharp  and  lancinating.  It  is  fre- 
quently severe  when  erosion  of  the  chest  wall  or  vertebrae  is  taking  place. 
Anginose  attacks  may -occur.  Pain  may  be  absent.  Broadbent  has  spoken 
of  aneurism  of  the  ascending  arch  as  the  aneurism  of  physical  signs;  of  the 
transverse  arch  as  the  aneurism  of  symptoms.  Pain  is  the  chief  symptom 
in  aneurism  of  the  abdominal  aorta.  It  is  epigastric,  paroxysmal,  and  radi- 
ates to  the  back  and  sides.  Severe  epigastric  pain  occurs  in  aneurism  of 
the  cceliac  axis  and  the  splenic  artery.  Pain  may  occur  in  mediastinal 
tumor,  but  it  is  much  less  common  than  in  aneurism  and  does  not  have  the 
radiating  character  so  common  in  the  latter  affection.  The  pain  of 
mediastinal  abscess  is  substernal,  throbbing,  and  usually  associated  with 
chilliness  and  profuse  sweating.  In  plastic  pericarditis  pain  may  be 
absent.  When  present  it  is  variable  in  intensity,  usually  mild,  exception- 
ally severe,  and  frequently  intensified  by  the  pressure  of  the  stethoscope. 
It  is  felt  in  the  precordia  or  at  the  base  of  the  ensiform  cartilage.  The  pain 
of*  pericarditis  with  effusion  is  sharp  and  lancinating  and  intensified  by 
pressure  over  the  ensiform  cartilage.  It  may  be  dull  and  dragging.  Pain 
is  not  a  symptom  of  endocarditis.  It  occurs  in  chronic  valvular  disease, 
especially  aortic  insufficiency,  in  which  it  is  sometimes  persistent  and 
distressing.  It  is  usually  precordial,  dull,  and  aching;  sometimes  sharp  and 
radiating  to  the  neck  and  down  the  left  arm.  Pain  is  much  less  common  in 
aortic  stenosis  and  is  not  a  prominent  symptom  in  mitral  disease  so  long  as 
compensation  is  maintained.  Angina  pectoris  is  characterized  by  par- 
oxysmal, agonizing  pain  in  the  region  of  the  heart,  radiating  into  the  neck 
and  arm-,  especially  into  the  ulnar  distribution  of  the  left  arm,  and  often 
attended  with  the  fear  of  impending  death.  Chest  pain  is  common  and 
severe  in  croupous  pneumonia,  pleurisy,  and  pulmonary  abscess.  It  may 
occur  in  any  pari  of  the  chest  but  is  most  common  in  the  inframammary 
and  mammary  regions.  In  some  cases  of  severe  acute  bronchitis  substernal 
pain  is  a  distressing  symptom.  Pain  may  be  absent  in  diseases  of  the 
liver.  It  occurs  in  acute;  infectious  cholecystitis  and  is  paroxysmal  and 
severe.  It  is  referred  to  the  region  of  the  liver  but  may  have  its  focus  of 
intensity  as  low  as  the  appendix  or  in  the  epigastrium.  Intense  paroxysmal 
pain  is  met  with  in  cancel-  of  (lie  bile  passages.     Biliary  colic  is  of  common 

38 


594  MEDICAL  DIAGNOSIS. 

occurrence  in  gall-stone  disease.  There  is  agonizing  pain  in  the  region  of 
the  gall-bladder,  extending  into  the  lower  thoracic,  epigastric,  and  upper 
abdominal  zones  and  radiating  to  the  right  shoulder.  Dull  dragging 
pain  with  intense  exacerbations  associated  with  nausea  or  vomiting  is 
encountered  in  so-called  hypertrophic  cirrhosis.  Pain  of  a  dull,  aching 
character  and  radiating  to  the  back  and  right  shoulder  occurs  in  hepatic 
abscess.  Pain  and  uneasiness  in  the  right  hypochondrium  are  present  in 
some  cases  of  cancer  of  the  liver.  In  pancreatic  disease  pain  may  be  a 
prominent  and  suggestive  symptom.  It  occurs  in  hemorrhage,  acute 
pancreatitis,  and  abscess  and  is  referred  to  the  upper  zone  of  the  abdomen. 
It  is  intense  and  persistent  with  agonizing  paroxysms.  Painful  colicky 
attacks  with  nausea  and  vomiting  have  been  noted  in  pancreatic  cysts  and 
the  passage  of  calculi  has  caused  pancreatic  colic.  A  dull  pain  under  the 
sternum  is  present  in  inflammation  and  in  spasm  of  the  oesophagus.  In 
cancer  it  may  be  persistent  or  only  present  upon  attempts  to  swallow  food. 
The  pain  of  gastralgia  is  usually  deeply  seated;  that  of  gastritis  more 
superficial.  Cardialgia  is  a  term  used  to  designate  the  uneasy  and  painful 
sensations  in  chronic  gastritis,  sometimes  caused  by  the  taking  of  food, 
sometimes  present  when  the  stomach  is  empty.  Pain  is  a  distinctive  symp- 
tom of  gastric  ulcer.  It  is  gnawing,  burning,  paroxysmal,  induced  by  tak- 
ing food,  and  referred  to  the  epigastrium.  It  is  also  in  some  cases  felt  in  the 
back  at  the  level  of  the  tenth  dorsal  vertebra.  In  peptic  ulcer  of  the  duo- 
denum the  pain  is  sometimes  located  in  the  right  hypochondrium  and  may 
come  on  two  or  three  hours  after  eating.  Pain  is  an  early  symptom  in 
cancer  of  the  stomach  and  occurs  at  some  period  in  almost  all  cases.  It  is 
usually  epigastric  but  may  be  felt  in  the  back  or  loins.  It  is  usually  burn- 
ing or  gnawing  and  rather  continuous  than  paroxysmal,  though  it  is  aggra- 
vated after  food.  The  gastric  crises  of  tabes  consist  of  intense  paroxysmal 
pain  in  the  stomach  accompanied  with  vomiting  and  an  excess  of  intensely 
acid  gastric  fluid.  Intestinal  diseases  are  accompanied  by  pain  which  may 
be  colicky  when  the  small  intestine  is  involved  and  bearing-down  when  the 
colon  is  affected — the  tormina  and  tenesmus  of  the  older  physicians. 
Abdominal  pain  of  variable  intensity  occurs  in  acute  and  chronic  catarrh, 
ileocolitis,  proctitis,  malignant  disease  of  the  intestines,  obstruction,  intus- 
susception, ileus,  and  appendicitis.  It  is  the  first  and  most  distinctive  symp- 
tom of  peritonitis.  Inframammary  pain  upon  the  left  side  is  a  common 
symptom  of  fecal  accumulations  in  the  sigmoid  flexure  of  the  colon  in 
women,  and  is  relieved  by  free  purgation.  Penal  colic  may  extend  well  into 
the  abdomen  upon  the  affected  side.  Pyelitis  may  cause  suprapubic  pain. 
Displaced  kidney  is  usually  a  source  of  much  discomfort;  often  of  distressing 
pain.  The  paroxysmal  pains  known  as  DietVs  crises  occur  in  this  condition. 
5.  Lead  colic,  the  referred  pain  of  diaphragmatic  pleurisy  felt  in  the 
right  hypochondrium,  and  the  girdle  sensations  of  disease  of  the  spinal 
cord  are  abdominal  pains  of  purely  nervous  origin.  The  last  may  be  a 
mere  sensation  of  a  cord  or  belt  around  the  waist  or  it  may  constitute  an 
actual  pain.  It  is  usually  upon  the  level  of  the  umbilicus  or  higher  but  may 
be  lower.  The  pain  is  sometimes  much  less  marked  upon  one  side  than 
upon  the  other  and  may  suggest  a  unilateral  new  growth  or  other  form  of 
one-sided  abdominal  disease. 


SYMPTOMS  AND  SIGNS:    PAIN.  595 

Pains  in  the  Extremities. — In  general  terms  the  diagnostic  significance 
is  the  same  for  the  arms  and  hands  and  for  the  legs  and  feet.  The  excep- 
tions are  mainly  as  follows:  The  pain  of  angina  pectoris  extends  to  the 
arms  and  especially  to  the  left  arm  and  involves  the  ulnar  distribution. 
The  pain  in  writer's  spasm  and  other  occupation  neuroses  involves  the 
forearms  and  hands.  It  consists  of  irregular  darting  pains  in  the  affected 
muscles  and  the  usual  pains  attending  the  spasm  upon  effort.  The  pains 
of  dactylitis,  onychia,  and  paronychia  involve  the  fingers.  Gout  occa- 
sionally affects  the  fingers,  but  usually  the  foot  and  especially  the  great  toe. 
A  group  of  painful  affections  are  due  to  improper  foot  wear — ingrowing  toe- 
nail, corns,  bunions  and  metatarsalgia.  The  pains  of  flat-foot,  varicose  veins 
and  varicose  ulcer  are  to  be  considered  in  regard  to  the  habitually  erect 
posture.  The  especial  liability  of  the  knee  and  ankle  to  troublesome  painful 
affections  and  the  greater  frequency  of  venous  thrombosis  in  the  lower 
extremity  are  due  to  postural  conditions  and  the  greater  distance  of  the 
blood-vessels  from  the  heart.  Referred  pains  are  common  in  the  lower 
extremities.  The  pain  in  hip-joint  disease  and  obturator  hernia  is  often 
referred  to  the  inner  side  of  the  knee;  that  of  ovarian  and  uterine  disease, 
fecal  impaction,  aneurism,  and  other  abdominal  tumors,  to  the  inner  sur- 
face of  the  corresponding  thigh,  and  in  rare  instances  that  of  acute  disease 
of  the  prostate  gland  to  the  sole  of  the  foot.  Pains  in  the  limbs  associated 
with  numbness  and  tingling  have  occasionally  been  observed  in  the  pre- 
hemiplegic  stage  of  cerebral  hemorrhage.  Pain  in  the  toes,  due  to  periph- 
eral neuritis,  is  an  occasional  affection  after  enteric  fever.  The  affection 
is  not  attended  by  the  signs  of  inflammation  and  passes  away  in  the  course 
of  some  days.  Painful  muscular  cramps  in  the  post-dormitium  usually 
involve  the  lower  extremities  and  in  particular  the  muscles  of  the  calf  of 
the  leg.  They  occur  in  pregnancy,  in  gouty  subjects,  and  in  persons  oth- 
erwise in  good  health.  Similar  painful  cramps  may  attend  violent  exer- 
tion and  exposure  to  cold,  as  in  swimmers. 

The  painful  affections  common  to  the  upper  and  lower  extremities, 
aside  from  traumatism  and  the  action  of  cold,  as  in  frost-bite,  involve  the 
muscles,  nerves,  blood-vessels,  articulations,  and  bones. 

1.  Pain  is  symptomatic  of  myalgia  from  unaccustomed  or  habitual 
overwork.  It  shows  itself  in  athletes,  dancers,  horseback  riders,  pedestrians 
and  soldiers  after  forced  inarches  and  is  without  diagnostic  significance. 
Muscular  pain  occurs  in  various  forms  of  myositis  and  especially  in  trich- 
iniasis.  General  muscular  pain  is  a  symptom  of  rickets:  It  occurs  in  scurvy 
and  is  distinctive  of  infantile  scorbutus,  in  which  it  is  a  prominent  symp- 
tom upon  both  voluntary  and  passive  movement  of  the  legs.  Painful 
cramp  upon  muscular  effort — intermittent  claudication — occurs  in  throm- 
bosis and  arteriosclerosis  of  the  lower  extremities. 

2.  Nervous  pain  is  symptomatic  of  neuralgia — tender  points;  par- 
oxysms, pressure  aggravation;  neuritis  either  intrinsic  or  from  pressure; 
peripheral  neuritis  or  neuromata.  Diffuse  pain  below  the  knees  is  especially 
common  in  alcoholic  neuritis.  Sciatica,  as  well  as  brachial  neuritis,  which  is 
the  same  thing  in  the  upper  extremity,  is  in  some  instances  a  neuralgia; 

in  others  a  neuritis  of  the  nerve  or  its  plexus.     Ii  is  almost  always  unilateral. 
Lightning  pains  occur  in  spinal  disease,  especially  tabes.     They  are  more 


596  MEDICAL  DIAGNOSIS. 

common  in  the  legs  than  in  the  arms.  They  are  sometimes  localized. 
Bilateral  neuralgic  pains  in  the  arms  and  legs  are  due  to  spinal  cord  disease 
as  sclerosis,  to  general  toxic  conditions  as  lead  or  arsenic,  to  vertebral 
disease,  or  in  the  lower  extremities  to  pressure  upon  the  nerve-roots  of  the 
cauda  equina. 

3.  Venous  thrombosis  —  milk-leg,  phlegmasia  alba  dolens  —  is  often 
extremely  painful.  It  occurs  in  lying-in  women  and  as  a  sequel  to  enteric 
fever  and  other  infectious  diseases.  A  similar  condition  may  occur  in 
consequence  of  local  pressure  in  the  upper  extremity.  Pain,  usually  tin- 
gling or  burning  in  character,  occurs  in  the  early  stages  of  local  gangrene, 
in  ergotismus,  diabetes,  and  Raynaud's  disease. 

4.  The  joints  are  especially  liable  to  pain.  Exquisite  pain  is  experienced 
in  the  joint  affection  of  rheumatic  fever.  The  wrists,  elbows,  knees,  and 
ankles  are  especially  liable  to  involvement.  Another  exquisitely  painful 
joint  affection  is  gout.  Arthritis  deformans  is  attended  by  occasional 
outbreaks  of  pain,  each  of  which  results  in  an  increase  of  the  previously 
existing  deformity  of  the  joints.  Many  of  the  cases  described  under  the 
term  chronic  rheumatism  belong  to  this  category.  The  pain  in  gonorrhceal 
arthritis  is  persistent  and  rebellious  to  treatment.  That  of  ordinary  syno- 
vitis is  of  moderate  intensity.  Pyaemic  joints  are  usually  exquisitely  painful. 
Postfebrile  arthritis  closely  resembles  the  joint  affection  of  rheumatic 
fever.  In  spinal  arthropathies — Charcot's  joints — and  in  tuberculous  joints 
pain  is  not  always  a  conspicuous  symptom. 

5.  All  forms  of  periostitis  are  accompanied  by  pain.  The  subperi- 
osteal hemorrhages  of  scurvy  are  attended  with  pain,  which  is  also  a  com- 
mon symptom  in  osteomyelitis  and  a  group  of  cases  of  osteitis  deformans. 

TENDERNESS. 

Tenderness  is  pain  upon  pressure.  It  usually  but  not  invariably  accom- 
panies spontaneous  pain.  Intestinal  colic  and  some  forms  of  neuralgia  are 
relieved  by  pressure.  Tenderness  may  be  present  in  the  absence  of  spon- 
taneous pain.  This  symptom  is  often  of  considerable  diagnostic  value, 
but  being  purely  subjective  it  is  liable  to  the  uncertainties  which  modify 
the  diagnostic  significance  of  spontaneous  pain.  It  is  attended  by  objec- 
tive manifestations,  as  wincing,  flinching,  exclamations  of  suffering,  and  the 
like.  As  in  the  case  of  spontaneous  pain  the  allegations  of  the  patient  can- 
not always  be  depended  upon.  In  certain  cases  tenderness  may  disappear 
when  his  attention  is  directed  to  other  objects,  or  it  may  be  present  under 
the  influence  of  suggestion  or  expectant  attention,  or  finally  it  may  be 
simulated  in  malingering. 

A  distinction  is  to  be  made  between  tenderness,  which  is  pain  upon 
pressure,  and  hyperesthesia,  which  is  an  exaggeration  of  the  sensibility 
of  the  skin.  Tenderness  is  (a)  superficial,  namely,  pain  upon  a  very  light 
touch;  or  (b)  deep,  that  is,  pain  excited  by  pressure  sufficiently  firm  to 
extend  to  underlying  parts.  Superficial  tenderness  is  closely  allied  to 
hyperesthesia  and  is  usually  coupled  with  a  diminution  of  the  power  to 
recognize  the  nature  of  the  agent  by  which  the  impression  is  caused — loss 
of  tactile  sensibility. 


SYMPTOMS  AND  SIGNS:   TENDERNESS.  597 

For  practical  purposes  tenderness,  like  pain.,  may  be  best  studied  in 
relation  to  the  parts  in  which  it  is  localized  and  the  anatomical  structures 
involved. 

The  Head. — Tenderness  of  the  scalp  occurs  during  and  after  the 
attack  in  migraine,  occipital  neuralgia,  and  in  hysterical  conditions.  Light 
pressure  or  the  use  of  the  comb  or  brush  may  excite  pain.  Local  tenderness 
is  present  in  traumatism,  especially  contusions,  and  subcutaneous  effusions 
of  blood.  Diffuse  tenderness  may  be  elicited  in  myalgia  of  the  occipito- 
frontalis  muscle.  Tenderness  attends  periostitis  and  caries  of  the  skull. 
It  is  present  also  in  gumma.  Tenderness  with  or  without  local  cedema  is 
symptomatic  of  infection  of  the  mastoid  sinuses — suppurative  mastoiditis. 
Localized  pain  is  produced  by  tapping  upon  the  skull  in  some  cases  of 
meningitis,  tumor,  and  abscess  of  the  brain — a  symptom  of  minor  impor- 
tance. 

The  Face. — Tenderness  immediately  in  front  of  the  tragus  is  pres- 
ent in  acute  inflammation  of  the  middle  ear.  Tenderness  over  the  malar 
bone  is  symptomatic  of  abscess  and  malignant  disease  of  the  antrum 
of  Highmore.  The  tender  points  in  trifacial  neuralgia  are  found  at  the 
emergence  of  the  branches  from  the  bony  foramina  and  their  pene- 
tration of  fascia?.  There  is  occasionally  also  sympathetic  tenderness  at 
the  occipital  protuberance  and  over  the  upper  cervical  spines.  Exqui- 
site hyperesthesia  is  encountered  in  some  cases  of  neuralgia  of  the 
fifth  nerve. 

The  Neck. — Localized  tenderness  is  found  in  acute  inflammatory 
conditions,  as  mumps,  cellulitis—  angina  Ludorici — acute  adenitis;  in 
myalgia,  the  spastic  rigidity  of  meningitis;  in  caries  of  the  cervical  verte- 
brae and  in  cervico-occipital  and  cervicobrachial  neuralgia. 

The  Thorax. — Tenderness  in  the  course  of  the  spine  occurs  in  men- 
ingitis, spondylitis,  arthritis  deformans  involving  the  spine,  periostitis, 
and  in  some  cases  of  myelitis.  It  is  a  symptom  of  importance  in  neuras- 
thenia, hysteria,  and  spinal  irritation,  and  in  lumbago.  Pressure  upon  the 
tender  points  produces  not  only  pain  but  also  marked  acceleration  of  the 
pulse — Mannkopff's  symptom.  Thoracic  aneurism  causing  erosion  of  the 
vertebra?  is  a  cause  of  tenderness  in  the  dorsal  or  lumbar  spine.  Spinal 
tenderness  may  frequently  be  found  in  lumbar,  subphrenic,  and  perinephric 
abscess,  and  has  been  observed  in  acute  inflammation  of  the  bronchial 
glands  and  in  some  cases  of  tumor  of  the  mediastinum.  In  these  condi- 
tions pain  may  be  also  called  forth  by  sudden  pressure  upon  the  shoulders 
of  the  patient  or  by  jarring  the  body,  as  by  a  misstep. 

Tenderness  attends  periostitis  and  caries  of  the  clavicles,  sternum 
ribs,  and  cartilages.  It  may  be  present  in  these  structures  in  the  painful 
form  of  osteitis  deformans,  especially  early  in  the  course  of  the  disease. 
It  is  found  in  abscess  of  the  wall  of  the  thorax,  perforating  empyema,  and 
eroding  aneurism.  Tender  points  are  present  in  intercostal  neuralgia. 
Tenderness  upon  percussion  is  not  uncommon  in  the  infraclavicular  regions 
in  phthisis.  The  mammse  sometimes  are  tender  at  the  menstrual  period, 
in  early  pregnancy,  in  the  condition  known  as  irritable  breast,  which  is  a 
syndrome  of  hysteria,  and  in  adenoma  and  malignant  tumor.  Tender- 
ness is  a  symptom  of  pericarditis. 


598  MEDICAL  DIAGNOSIS. 

Abdominal  tenderness  is  a  very  common  symptom.  It  may  be 
general,  as  in  peritonitis,  or  local.  The  latter  is  usually  present  in  a  limited 
area,  as  the  epigastric,  hypochondriac,  umbilical,  hypogastric,  or  iliac 
regions;  or  the  tenderness  may  be  found  in  one  of  the  quadrants  of  the 
abdomen.  Sometimes  the  tenderness  is  distinctly  focal,  as  in  peptic  ulcer, 
the  McBurney  point  in  appendicitis,  the  region  of  the  gall-bladder,  or 
pyosalpinx.  In  other  cases  it  is  diffused,  with  or  without  circumscribed 
areas  of  intensit}^. 

Epigastric  tenderness  is  a  symptom  in  acute  and  some  cases  of  chronic 
gastritis,  pancreatitis,  pericarditis,  acute  yellow  atrophy  of  the  liver,  and 
disease  of  the  gall-bladder  and  bile  passages.  It  may  be  found  in  some  cases 
of  Addison's  disease.  One  or  more  tender  points  are  present  in  peptic 
ulcer.  Tenderness  in  this  region  attends  the  myalgia  of  persistent  cough 
and  may  be  observed  in  hysteria  and  hypochondriasis. 

Tenderness  in  the  right  hypochondrium  is  encountered  in  various 
diseases  of  the  liver,  as  perihepatitis,  congestion,  acute  hepatitis,  abscess, 
cancer,  acute  }^ellow  atrophy,  and  in  diseases  of  the  gall-bladder  and  bile- 
ducts,  including  cholelithiasis.  In  the  last  group  of  cases  the  tenderness 
may  be  confined  to  the  region  of  the  gall-bladder,  or  diffused  over  the 
hepatic  area  or  even  more  widely;  in  the  left  hypochondrium  in  acute 
distention  of  the  spleen,  infarct,  perisplenitis,  pancreatitis,  and  fecal 
impaction;  in  either  hypochondrium  in  diaphragmatic  pleurisy;  in  both 
in  influenza,  relapsing  fever,  and  the  gastrohepatic  form  of  estivo- 
autumnal  malarial  fever.  Tenderness  in  the  umbilical  region  may  be 
elicited  in  peritonitis,  enteritis,  and  enteric  fever;  in  the  right  iliac  region 
in  enteric  fever,  appendicitis,  renal  calculus,  fecal  accumulations  in  the 
hepatic  flexure  of  the  colon,  and  in  cancer;  in  the  left  iliac  region  in  can- 
cer of  the  sigmoid  flexure  and  in  some  cases  of  membranous  colitis;  in 
either  in  pelvic  inflammations  and  diseases  of  the  tubes  and  ovaries;  in 
both  when  any  of  these  conditions  are  bilateral,  and  in  hysteria.  Hypo- 
gastric tenderness  may  be  symptomatic  of  cystitis,  inflammation  of  the 
pelvic  organs,  dysmenorrhea,  and  hysteria. 

The  Extremities. — Cutaneous  hyperesthesia  may  be  due  to  peripheral 
neuritis,  especially  the  alcoholic  form,  neuritis  involving  a  nerve-trunk 
in  the  course  of  which  there  are  tenderness  upon  pressure  and  'points  dou- 
loureux, crural  thrombosis,  varicose  veins;  to  periostitis,  osteitis,  osteo- 
sarcoma, arthritis,  myalgia,  myositis,  rickets,  scurvy,  trichiniasis,  or  tetanus. 
Forms  of  arthritis  especially  characterized  by  pain  and  tenderness  are 
encountered  in  rheumatic  fever,  the  acute  process  in  arthritis  deformans, 
the  gonorrhceal  joint  infection,  gout,  sprain,  and  tuberculosis.  The  hyster- 
ical knee  is  usually  exquisitely  painful  upon  pressure. 

PARESTHESIA. 

Paresthesia  is  a  condition  of  modification  of  normal  sensibility.  The 
phenomena  are  due  to  irritation  of  the  sensory  nerves  in  their  course  or 
distribution.  They  depend  upon  nutritive  disturbances  of  the  nervous 
system  or  the  action  of  toxic  or  irritating  substances  in  the  blood.  The 
itching  of  mild  morphine  intoxication  is  an  example.     Similar  symptoms 


SYMPTOMS  AND  SIGNS:   PARESTHESIA.  599 

occur  in  gout  and  litha?mia  and  are  met  with  in  neurasthenia  and  hysteria. 
Sensations  of  numbness,  burning,  stinging,  itching,  and  formication  are 
common.  Coldness,  weight,  tenesmus,  the  girdle  sensation,  precordial 
constriction,  tightness,  throbbing,  sinking,  faintness,  and  debility  also 
belong  to  this  group  of  symptoms.  The  sensations  are  closely  allied  to  pain 
and  are  often  described  as  painful  by  the  patients.  They  are  wholly  sub- 
jective and  their  value  in  diagnosis  rests  entirely  upon  the  ability  of  the  phy- 
sician to  estimate  the  patient's  accuracy  of  expression  and  desire  to  com- 
municate the  truth.    There  is  no  objective  method  of  testing  his  statements. 

These  perversions  of  sensibility  are  very  common  and  in  many  instances 
constitute  the  principal  if  not  indeed  the  only  symptom  of  which  patients 
complain.  They  are  much  more  common  in  women  than  in  men  and  in 
the  well-to-do  than  in  the  poor.  Common  associated  conditions  are  defec- 
tive digestion,  constipation,  anaemia,  and  general  malnutrition.  Impor- 
tant etiological  factors  are  overwork,  worry,  irregular  or  indifferent  meals, 
the  stress  of  life,  too  frequent  child-bearing,  prolonged  lactation,  and  enter- 
optosis.  Remarkable  forms  and  combinations  are  described  by  women 
passing  through  the  grand  climacteric.  Forms  of  general  and  local  pares- 
thesia constitute  important  epiphenomena  of  many  chronic  morbid  states. 

Cerebral  Paresthesias . — Sensations  of  heat,  fulness,  pressure,  and 
other  abnormal  sensations  in  the  head — the  so-called  cerebral  parcesthesioe — 
occur  in  neurotic  individuals  and  over-taxed  brain  workers.  These  abnor- 
mal sensations  do  not  amount  to  actual  pain,  though  they  frequently  alter- 
nate with  it.  They  are  often  distressing  and  sometimes  intense.  They 
occur  in  adolescence  and  early  adult  life  and  are  especially  common  in  women 
about  the  time  of  the  grand  climacteric.  They  are.  however,  more  com- 
mon in  men  than  in  women  and  in  those  given  to  intellectual  pursuits  and 
of  sedentary  habits  than  among  the  laboring  classes.  They  occur  with 
great  frequency  in  lithsemic  and  gouty  individuals.  These  sensations  are 
sometimes  general,  sometimes  localized  to  the  vertex,  occiput,  or  forehead. 
They  frequently  persist  for  long  periods  of  time,  in  some  cases  preserving 
the  same  character,  in  others  varying.  They  are  augmented  by  mental 
effort  and  by  disagreeable  emotions  and  intensified  by  introspection  and 
attempts  on  the  part  of  the  patient  to  explain  them  to  his  physician. 
They  are,  on  the  other  hand,  minimized  by  diversion  and  suggestion. 

Forms  of  Paresthesia. — The  paraesthesiae  may  be  best  studied  in 
respect  of  their  character,  since  almost  any  of  them  may  be  referred  to 
valines  parts  of  the  body  and  all  parts  at  different  times.  They  are  de- 
scribed in  the  most  varied  combinations,  so  that  numbness  and  tingling, 
itching  and  formication,  burning  and  stinging,  coldness  and  tension,  tight- 
ness and  throbbing,  and  many  others  occur. 

Numbness. — This  is  a  common  symptom  in  superficial  injuries  of  the 
skin  from  cold  or  heat;  the  action  of  corrosive  substances,  as  the  mineral 
acids  and  carbolic  acid;  overdoses  of  certain  drugs,  as  aconite  and  the 
bromides;  injuries  of  nerves,  neuritis,  neuralgia  in  the  stage  of  access  and 
decline  and  in  the  remissions  of  pain;  herpes  zoster;  peripheral  neuritis 
from  any  cause  and  in  the  endemic  form  of  the  tropics,  beriberi;  hysteria, 
neurasthenia,  tetany,  tabes,  the  early  stages  of  myelitis,  and  in  cerebro- 
spinal fever.     Numbness  may  be  a  localizing  symptom  in  coarse  lesions  of 


600  MEDICAL  DIAGNOSIS. 

the  brain,  as  tumor  or  abscess.  It  may  occur  as  a  premonitory  symptom 
in  apoplexy  and  as  the  aura  in  epilepsy.  The  sensation  is  sometimes  de- 
scribed as  like  that  produced  by  a  very  mild  faradic  current.  It  is  common 
and  distressing  in  myxcedema  and  may  be  a  troublesome  symptom  affect- 
ing the  hands  and  feet  in  arthritis  deformans.  Numbness  in  the  hands  and 
feet  constitutes  the  condition  known  as  acroparesthesia.  Waking  numb- 
ness occurs  at  or  about  the  menopause.  It  involves  the  extremities  and 
usually  passes  off  as  the  day  goes  on  and  ceases  when  the  patient  becomes 
adjusted  to  the  non-menstrual  life.  Numbness  is  sometimes  associated 
with  or  alternates  with  burning  and  tingling. 

Itching  or  Pruritus. — This  form  of  paresthesia  is  frequently  asso- 
ciated with  formication  and  is  sometimes  so  severe  as  to  be  described  as 
pain.  It  is  also  associated  with  burning,  especially  in  inflammations  of 
the  skin  such  as  occur  in  the  exanthemata,  as  measles  and  scarlet  fever. 
Itching  of  the  scalp  is  a  symptom  of  seborrhcea;  of  the  lips  and  nose  a 
symptom  of  herpes;  of  the  eyelids  a  symptom  of  beginning  conjunctivitis; 
of  the  anal  region  a  symptom  of  hemorrhoids  or  ascarides;  of  the  external 
genitalia  in  both  sexes  a  symptom  of  saccharine  diabetes,  in  the  female  of 
leucorrhcea  and  neurotic  states.  Itching  of  the  whole  surface  is  a  trouble- 
some symptom  in  aged  persons,  in  certain  subjects  in  winter,  in  others 
who  are  lithaemic  or  gouty,  in  hysteria,  neurasthenia,  and  many  organic 
diseases  of  the  nervous  system.  It  is  a  symptom  of  jaundice,  and  some- 
times follows  the  administration  of  morphine,  copaiba,  and  other  drugs. 
Pruritus  is  an  occasional  symptom  in  chronic  interstitial  nephritis  and 
chronic  lead  poisoning. 

Coldness. — A  common'  form  of  paresthesia.  It  is  often  general,  as 
in  the  chill,  rigor,  or  shivering  which  marks  the  onset  of  an  acute  febrile 
infection  as  pneumonia,  or  constitutes  the  initial  stage  of  ague.  Under 
these  circumstances  the  internal  temperature  is  elevated.  Sensations  of 
coldness  with  a  normal  or  subnormal  temperature  occur  in  myxcedema, 
profound  asthenia  from  any  cause,  especially  after  hemorrhage,  hysteria, 
neurasthenia,  and  in  some  forms  of  spinal  cord  disease,  as  tabes,  lateral 
sclerosis,  and  syringomyelia.  Coldness  in  the  back  is  often  experienced 
by  persons  who  are  suffering  from  pulmonary  tuberculosis  in  the  period 
of  incipiency.  Subjective  sensations  of  coldness  in  the  extremities  are 
usually  associated  with  actual  low  temperature  and  often  with  some  degree 
of  cyanosis.  In  other  cases  the  sensation  of  coldness  is  referred  to  a  cir- 
cumscribed area,  usually  in  the  leg  or  thigh.  The  affected  region  feels  as 
though  in  contact  with  a  piece  of  cold  metal  or  even  a  piece  of  ice.  This 
symptom  occurs  in  neuropathic  persons  usually  in  middle  life  and  com- 
monly in  men.  It  has  been  observed  in  local  injury  to  a  nerve-trunk  and 
in  spinal  diseases. 

Heat. — Heat  as  a  subjective  sensation  not  dependent  upon  general 
or  local  elevation  of  temperature  constitutes  a  common  and  distressing 
paresthesia.  When  it  amounts  to  pain  it  is  known  as  causaJgia.  It  is 
mostly  localized.  Flushing  is  accompanied  by  the  sensation  of  heat. 
Flushes  of  heat  are  common  in  stout  women  at  middle  life,  at  or  about 
the  menopause,  and  in  nervous  persons  with  weak  heart.  Subjective 
sensations  of  heat  are  sometimes  associated  with  the  girdle  sensation. 


SYMPTOMS  AND  SIGNS:    PARESTHESIA.  601 

Weight. — This  paresthesia  is  likewise  of  common  occurrence.  It 
occurs  in  the  chest  as  a  symptom  in  severe  acute  bronchitis,  asthma,  pleural 
and  pericardial  effusion,  and  mediastinal  tumor;  also  in  great  cardiac  hyper- 
trophy and  dilatation  and  in  valvular  disease  upon  rupture  of  compensa- 
tion. Substernal  weight  and  oppression  may  be  a  symptom  of  acute  indi- 
gestion or  of  an  overloaded  stomach  and  may  precede  haematemesis.  The 
sensation  may  be  referred  to  the  epigastrium.  Weight  upon  the  chest 
occurs  in  hysteria  and  neurasthenia  and  constitutes  the  incubus  in  night- 
mare. It  is  symptomatic  of  enteroptosis  and  splanchnoptosis,  ascites,  and 
abdominal  and  pelvic  tumors. 

Tenesmus  or  Bearing  Down. — This  form  is  frequently  so  distress- 
ing as  to  amount,  to  actual  pain.  The  milder  forms  are  encountered  in 
over-distention  of  the  bladder,  straining  at  stool,  and  some  varieties  of 
dysmenorrhea. 

Precordial  constriction  or  stenocardia  accompanies  the  pain  of 
angina  pectoris.  Similar  sensations  but  much  less  intense  are  sometimes  ex- 
perienced in  cardiac  asthenia,  myocarditis,  fatty  heart,  pericarditis,  and  when 
the  heart  is  displaced  upward  by  large  ascites  or  abdominal  tympany. 
It  belongs  also  to  the  wide  group  of  sensations  in  hysteria  and  neurasthenia. 

Throbbing. — Sensations  of  throbbing  are  felt  in  conditions  charac- 
terized by  vascular  relaxation  and  nervous  excitement.  Among  these  are 
aortic  regurgitation,  anaemia,  and  paroxysmal  states  in  hysteria  and  neuras- 
thenia. Almost  every  part  of  the  body  may  be  the  seat  of  these  sensations. 
They  affect  the  head  in  migraine  and  other  intense  headaches;  the  neck 
in  front  and  laterally  in  cardiac  hypertrophy  and  exophthalmic  goitre; 
the  precordia  in  palpitation;  the  epigastrium  in  the  pulsating  aorta  of 
neurasthenia;  and  constitute  a  local  symptom  in  phlegmon  and  aneurism. 
Throbbing  is  commonly  associated  with  objective  pulsations.  Purely 
subjective  sensations  of  fluttering  are  described  by  nervous  women.  They 
are  often  referred  to  the  left  inframammary  region. 

Faintness. — Faintness  is  a  sensation  attendant  upon  enfeeblement 
of  the  heart's  action,  whether  due  to  physical  or  emotional  causes.  Hence 
it  occurs  in  dilated  heart,  myocarditis,  fatty  heart,  and  all  forms  of  anaemia, 
especially  upon  exertion;  in  hemorrhage,  shock,  collapse,  and  upon  the  too 
sudden  withdrawal  of  fluid  by  the  trocar  or  aspiration;  and  finally  in 
fatigue,  excessive  heat,  and  intense  pain.  Faintness  attends  sudden  depress- 
ing emotion  and  mental  shock.  Weakness  and  debility  are  attended  by 
subjective  sensations  which  are  characteristic  and  important,  since  they 
are  often  danger  signals  in  the  absence  of  the  objective  phenomena  of 
oncoming  disease.  Sudden  sensations  of  weariness  out  of  all  proportion  to 
effort — fatigue  symptoms — are  suggestive  of  neurasthenia. 


602  MEDICAL  DIAGNOSIS. 


XIV. 

GENERAL    SYMPTOMATIC   DISORDERS   OF  THE   NERVOUS 

SYSTEM  (CONTINUED):    VERTIGO;   CONVULSIONS; 

TREMOR;    FIBRILLARY  TWITCHINGS. 

VERTIGO. 

Vertigo — literally  a  turning — is  a  symptomatic  derangement  of  the 
nervous  system  governing  the  relationship  of  the  body  to  external  objects. 
It  is  of  two  kinds:  objective  vertigo,  characterized  by  sensations  of  move- 
ment on  the  part  of  surrounding  objects  which  are  really  at  rest,,  and 
subjective  vertigo,  characterized  by  sensations  of  movement  on  the  part  of 
the  individual  himself.  It  is  popularly  known  as  dizziness  or  giddiness. 
This  symptom  attends  organic  intracranial  disease,  but  is  more  common  in 
peripheral  or  functional  disturbance.  Vertigo  in  which  no  underlying 
pathological  condition  is  discoverable  is  known  as  essential.  Vertigo  is  a 
common  nervous  symptom.  It  is  often  associated  with  headache.  It  may 
occur  (1)  in  mild  cerebral  concussion;  (2)  circulatory  disturbances,  as 
cerebral  ana?mia  and  hyperemia;  (3)  local  nerve  irritation,  as  mechanical 
irritation  of  the  external  auditory  meatus,  inflammation  of  the  middle  ear, 
or  the  application  of  electrical  currents  to  the  head.  A  special  form  of 
vertigo — true  auditory  vertigo — occurs  in  labyrinthine  disease.  (4)  Vertigo 
is  a  common  symptom  in  toxiemic  conditions  and  is  associated  with  head- 
ache in  the  period  of  onset  of  the  acute  infections,  in  many  cases  of  acute 
and  subacute  gastrohepatic  derangements,  and  in  lithsemia.  It  is  symp- 
tomatic of  narcotic  poisoning,  especially  that  produced  by  alcohol,  tobacco, 
opium,  and  the  nitrites.  It  occurs  also  in  aniline  poisoning.  (5)  It  is  a 
common  symptom  ir?  arteriosclerosis  and  (6)  in  valvular  disease  of  the 
heart,  especially  aortic  insufficiency,  and  in  forms  of  degenerative  myo- 
carditis; (7)  in  neuropathic  conditions,  especially  neurasthenia  and  epi- 
lepsy; (8)  in  reflex  disturbances,  such  especially  as  arise  from  diseases  of 
the  visual  apparatus  or  the  stomach;  (9)  in  organic  disease  of  the  brain, 
especially  in  tumor,  cerebellar  disease,  in  meningeal  irritation  and  menin- 
gitis, and  in  brain  syphilis.  Finally,  (10)  vertigo  results  from  mechanical 
causes,  such  as  swinging,  certain  unusual  postures,  rapid  rotary  move- 
ments, and  sea-sickness. 

Vertigo  varies  in  intensity  from  a  trifling  sensation  of  imperfect 
equilibrium — mere  swimming  of  the  head — to  the  most  active  and  dis- 
tressing sensations  of  rapid  or  irregular  movement  or  whirling  of  the  body 
or  of  surrounding  objects. 

The  equilibrium  of  the  body  is  maintained  by  muscular  action.  The 
nicely  adjusted  and  constantly  varying  motor  impulses  necessary  to  equi- 
librium are  determined  in  cerebral  centres  in  response  to  sensory  impres- 
sions which  are  as  continuous  as  the  motor  impulses  which  respond  to  them. 
These  sensory  impulses  are  visual,  aural,  muscular,  articular,  cutaneous. 


SYMPTOMS  AND  SIGNS:   VERTIGO.  603 

and  visceral.  Anything  which  suddenly  deranges  the  continuous  and 
systematized  though  unconscious  sensory  impulses  from  these  structures 
causes  a  derangement  of  the  nervous  mechanism  by  which  the  body  is 
maintained  in  its  relation  to  external  objects.  This  derangement  mani- 
fests itself  as  vertigo.  These  sensory  impressions  are  not  felt  in  normal 
consciousness,  but  when  they  are  interrupted  or  when  the  cortical  processes 
by  which  they  are  converted  into  motor  impulses  are  deranged  consciousness 
in  regard  to  them  is  perverted  and  vertigo  results.  For  this  reason  vertigo 
implies  a  disturbance,  not  a  loss  of  consciousness.  In  true  vertigo  con- 
sciousness is  always  retained. 

Vertigo  comes  on  suddenly  and  is  commonly  of  short  duration.  In 
the  objective  form  the  floor  or  the  bed  on  which  the  patient  is  lying  appears 
to  rise  and  sink  and  objects  whirl  around,  usually  in  a  definite  direction. 
In  subjective  vertigo  the  patient  himself  appears  to  be  whirling  around  or 
rising  and  sinking  in  space.  These  sensations  are  often  accompanied  by 
compensatory  movements  on  the  part  of  the  patient  which  may  result  in 
a  fall.  Mental  confusion,  faintness,  a  sense  of  alarm,  and  nausea  or  vomit- 
ing are  associated  symptoms,  which  vary  in  intensity  but  are  almost  al- 
ways present.  When  the  vertigo  is  severe  consciousness  is  impaired  but 
not  lost.  The  attacks  continue  to  recur  whilst  the  causal  condition  per- 
sists.    The  term  status  vertiginosis  has  been  applied  to  persistent  vertigo. 

The  following  forms  of  vertigo  demand  separate  consideration: 

Aural  Vertigo. — This  symptom  frequently  arises  from  the  pressure 
of  accumulated  cerumen  in  the  external  auditory  canal  or  from  the  pres- 
sure of  air  against  the  tymjDanic  membrane  by  a  blow  upon  the  ear,  or  the 
entrance  of  water  in  diving  or  surf  bathing,  or  the  too  forcible  use  of  the 
ear  syringe.  It  may  also  occur,  though  it  is  not  a  common  symptom,  in 
cases  of  middle-ear  disease  or  from  the  use  of  the  Eustachian  catheter. 
Vertigo  occurring  under  the  above  circumstances  is  usually  slight  and 
transitory.    Labyrinthine  vertigo  is  the  chief  symptom  in  Meniere's  disease. 

Toxic  Vertigo. — Vertigo  which  attends  the  onset  of  the  acute  infec- 
tions is  of  no  great  importance  and  usually  quickly  passes  away.  That 
which  occurs  in  gastrohepatic  catarrh  is  commonly  annoying  on  rising  in 
the  morning  in  persons  of  bilious  temperament  and  sedentary  lives,  espe- 
cially if  they  be  addicted  to  the  pleasures  of  the  table.  This  symptom 
occurs  also  in  acute  indigestion  and  in  litlucmic  conditions.  Vertigo  is 
a  very  common  drug  symptom,  which  is,  however,  much  influenced  by 
habit  and  idiosyncrasy. 

Cardiovascular  Vertigo. — Vertigo  is  a  symptom  of  cerebral  anaemia. 
It  occurs  in  sudden  blood  loss,  cardiac  asthenia,  excitement,  or  sudden 
effort  during  digestion,  upon  sudden  effort  in  myocarditis,  valvular  disease, 
and  in  particular  aortic  insufficiency.  It  occurs  also  in  pernicious  and  other 
forms  of  ansBmia,  chlorosis,  and  leukaemia.  Associated  with  tinnitus  aurium 
it  is  very  common  in  sclerotic  changes  in  the  branches  of  the  cerebral 
arteries. 

Neurotic  Vertigo. — Vertigo  sometimes  occurs  in  epilepsy  as  an  aura. 
It  is  not  rare  in  petit  tnal.  Vertigo  is  a  common  and  distressing  symptom 
in  neurasthenia.  The  attacks  are  frequent  but  not  commonly  severe  or 
prolonged.    They  are  attended  with  nausea,  though  vomiting  is  not  com- 


604  MEDICAL  DIAGNOSIS. 

mon.  It  is  usually  subjective  and  frequently  reflex.  Stumbling  or  para- 
lyzing vertigo  has  been  observed  in  exophthalmic  goitre  and  as  an  endemic 
condition  in  certain  cantons  of  Switzerland  during  the  summer.  There  is 
a  sudden  loss  of  power  in  the  legs  with  impairment  of  consciousness.  Par- 
oxysmal vertigo  may  occur  in  nervous  individuals  after  excitement  or 
fatigue.  It  is  very  distressing,  occurring  suddenly,  accompanied  with 
nausea  and  vomiting,  and  lasting  sometimes  for  hours. 

Reflex  vertigo  may  be  associated  with  the  brow  pains  and  other  forms 
of  headache  which  are  symptomatic  of  errors  in  refraction  or  want  of 
harmonious  action  in  the  ocular  muscles. 

Mechanical  Vertigo. — This  symptom  attends  sudden  lowering  of 
the  head,  whirling  around,  or  swinging  in  individuals  not  accustomed  to  it, 
and  is  a  very  important  part  of  the  symptom-complex  in  sea-sickness  and 
car-sickness.     Mild  persistent  vertigo  has  been  observed  in  elevator  boys. 

Vertigo  of  Intracranial  Disease. — This  is  a  very  common  symp- 
tom in  diseases  of  the  brain  and  its  meninges.  It  is  sometimes  distressing 
but  as  a  rule  is  of  secondary  importance  to  the  headache,  vomiting,  and 
mental' dulness  with  which  it  is  commonly  associated.  It  occurs  at  some 
time  during  the  course  of  meningitis,  cerebral  abscess,  thrombotic  soften- 
ing, tumor  of  the  brain,  and  cerebellar  disease.  This  form  is  of  considerable 
importance  in  the  diagnosis  of  cerebral  syphilis. 

Laryngeal  vertigo,  better  called  laryngeal  epilepsy,  usually  mani- 
fests itself  in  neurotic  adults.  The  paroxysm  begins  with  tickling  or  irrita- 
tion in  the  larynx,  cough,  partial  loss  of  consciousness,  and  dyspnoea.  Light 
tonic  or  clonic  movements  occur.  The  patients  suffer  from  laryngitis, 
bronchitis,  asthma,  or  pulmonary  phthisis.  The  attacks  recur  as  often  as 
once  a  day  or  at  longer  intervals. 

CONVULSIONS. 

The  term  convulsion  is  used  to  designate  a  paroxysm  of  involuntary 
and  more  or  less  violent  muscular  contractions  involving  the  voluntary 
muscles  in  general.  The  word  spasm  is  frequently  used  in  a  more  limited 
sense  to  indicate  similar  involuntary  contractions  of  the  muscles  of  partic- 
ular parts  of  the  body.  We  speak  of  general  convulsions  and  local  spasms. 
This  distinction  is,  however,  not  always  observed. 

General  Convulsions. — Convulsions  are  tonic  and  clonic.  A  tonic 
convulsion  is  an  involuntary  muscular  contraction  which  is  continuous 
and  intense.  It  may  be  of  bi'ief  duration,  as  in  the  beginning  of  the  epileptic 
paroxysm;  or  prolonged,  as  in  tetanus.  A  clonic  convulsion  is  character- 
ized by  the  rapid  alternation  of  contraction  and  relaxation,  as  in  the  second 
stage  of  the  epileptic  paroxysm  or  in  infantile  eclampsia.  The  posture  in 
tonic  convulsions  is  forced  and  immovable;  in  clonic  convulsions  it  is  con- 
stantly changed.  The  arms  and  legs  are  alternately  flexed  and  extended 
with  more  force  than  in  ordinary  movements,  the  body  is  violently  tossed, 
and  the  muscles  of  the  face  contorted.  The  chief  centre  for  convulsions  is 
the  cerebral  cortex.  Tonic  and  clonic  convulsions  may  succeed  each  other, 
as  in  epilepsy,  or  may  alternate,  as  in  hysteria.  Consciousness  is  often  pre- 
served in  general  convulsions  of  the  tonic  type,  as  strychnine  poisoning  and 


SYMPTOMS  AND  SIGNS:  CONVULSIONS.  605 

tetanus,  and  usually  lost  in  those  of  clonic  type,  as  epilepsy  and  uraemia. 
A  spasm  may  be  confined  to  a  muscle  or  a  group  of  muscles;  or  it  may  ex- 
tend to  an  entire  limb  or  the  whole  of  the  body.  A  cramp  is  a  painful 
tonic  spasm  affecting  a  single  muscle  or  group  of  muscles,  as  the  well- 
known  cramp  in  the  calves  of  the  legs. 

Etiology. — From  the  standpoint  of  etiology  convulsions  are  symp- 
tomatic of  (1)  local  irritation;  (2)  general  cortical  irritation,  (a)  from 
causes  wholly  unknown,  (b)  from  the  toxaemia  of  infection,  (c)  from  va- 
rious intoxications;  (3)  circulatory  derangements;  (4)  inflammatory  and 
degenerative  processes  involving  the  cerebral  cortex;  (5)  convulsions  are 
very  often  of  reflex  origin. 

Convulsions  are  essentially  paroxysmal.  Even  though  the  cause  is 
persistent,  the  motor  centres  become  exhausted  and  there  are  intermis- 
sions, as  in  .uraemia.  Again  the  paroxysms  occur  as  storms,  the  cause 
exhausting  itself  in  a  single  paroxysm  or  series  of  paroxysms  and  only 
again  asserting  itself  after  an  interval  more  or  less  prolonged,  as  in  ordi- 
nary epilepsy.  In  infancy,  in  the  children  of  neurotic  parents,  and  in  neuro- 
pathic individuals  convulsions  frequently  arise  from  the  action  of  causes  not 
capable  of  producing  them  at  a  later  age  or  in  normal  individuals. 

1.  Local  Irritation. — The  motor  areas  may  be  directly  involved 
in  fracture,  hemorrhage,  cicatrix,  or  neoplasm,  as  in  focal  or  Jacksonian 
epilepsy.  The  initial  symptom  may  be  a  local  spasm,  involving  the  leg, 
arm,  or  face,  the  convulsion  becoming  generalized  in  the  course  of  a  few 
seconds  or  longer.  Again  the  local  irritation  may  be  transmitted  from  a 
distance,  as  in  tumor,  abscess,  or  sclerosis. 

2.  The  irritation  may  be  general,  (a)  from  causes  wholly  unknown, 
as  in  epilepsy.  The  paroxysm  is  frequently  preceded  by  an  aura;  it  begins 
with  tonic  spasm  and  loss  of  consciousness  and  is  characterized  by  clonic 
convulsions.  So  characteristic  is  the  latter  stage,  that  general  convulsions 
due  to  other  causes  are  described  as  epileptiform  or  epileptoid.  The  par- 
oxysm is  followed  by  hebetude,  drowsiness,  or  stupor,  and  may  be  replaced 
by  a  maniacal  outbreak  or  other  mental  disturbance — the  psychicul  epi- 
leptic equivalent,  (b)  The  toxaemias  of  infection.  General  convulsions  very 
commonly  attend  the  onset  of  the  infectious  diseases  in  childhood.  They 
occur  at  this  period  of  life  as  the  equivalent  of  the  initial  chill  in  the  adult 
and  are  frequently  seen  at  the  onset  of  scarlet  fever,  measles,  and  pneumonia, 
and  in  other  not  well  defined  infections.  They  are  frequent  in  rickets, 
which  is  the  most  important  predisposing  cause  of  infantile  convulsions. 
They  are  early  symptoms  of  that  disease,  and  when  convulsions  occur  in 
infancy  without  manifest  cause  rickets  is  to  be  considered.  The  convul- 
sions of  tetanus,  strychnine  poisoning,  and  hydrophobia  are  to  be  considered 
under  this  heading,  (c)  General  convulsions  occur  in  poisoning  from 
aconite,  prussic  acid,  and  veratrum  viride,  and  in  chronic  alcoholism  and 
lead  poisoning.  Under  this  heading  are  to  be  included  the  convulsions  of 
uraemia,  puerperal  eclampsia,  and  asphyxia. 

3.  Circulatory  derangements  are  sometimes  the  cause  of  general 
convulsions  which  occur  after  profuse  hemorrhages,  and  in  the  cerebral 
anemia  which  immediately  precedes  dissolution.  Violent  general  convul- 
sions occasionally  occur  during  the  coma  following  sunstroke. 


606  MEDICAL  DIAGNOSIS. 

4.  Inflammatory  and  degenerative  processes  involving  the  cere- 
bral cortex  give  rise  to  general  convulsions.  Under  this  heading  are  to- 
be  considered  the  convulsions  of  cerebrospinal  fever  and  other  forms  of 
meningitis,  cerebral  syphilis,  general  paresis,  and  pachymeningitis  hsemor- 
rhagica. 

5.  Convulsions  are  very  often  of  reflex  origin.  Painful  affections  and 
excitation  in  the  region  of  a  sensory  nerve  may  produce  spasms.  Exam- 
ples of  reflex  convulsions  are  those  following  severe  injuries,  burns,  those 
associated  with  renal  or  intestinal  colic,  a  foreign  body  in  the  ear,  intestinal 
strangulation,  retention  of  urine,  and  phimosis.  Dentition  and  intestinal 
worms  are  less  common  causes  of  convulsions  than  is  generally  supposed. 
Indigestion  is  a  cause  of  convulsions  in  infants  and  older  children.  In 
whooping-cough  convulsions  are  very  common.  They  result  from  the 
asphyxia  attendant  upon  a  prolonged  paroxysm,  cerebral  congestion,  or 
hemorrhage  resulting  from  such  a  paroxysm.  In  other  cases  they  are  to 
be  attributed  to  the  depressed  condition  of  the  nervous  system  caused  by 
the  disease  itself.  General  convulsions  have  been  attributed  to  enlarge- 
ment of  the  thymus  gland  as  a  result  of  pressure  either  upon  the  pneumo- 
gastric  or  upon  the  trachea.  They  frequently  occur  in  children  in  whom  no 
cause  can  be  discovered  and  may  in  such  cases  be  regarded  as  idiopathic.  In 
infants  in  whom  an  attack  of  convulsions  has  once  occurred  a  predisposition 
seems  to  be  established,  so  that  similar  attacks  occur  from  indifferent  or  not 
recognizable  causes.  In  infantile  convulsions  the  attack  is  commonly  pre- 
ceded by  restlessness,  fretfulness,  grinding  of  the  teeth,  and  slight  twitching. 
It  may  occur  suddenly  without  premonitory  symptoms.  The  initial  cry  so 
common  in  epilepsy  is  usually  absent,  nor  are  the  successive  stages  so  well 
defined.  The  spasm  begins  in  the  hands;  the  eyes  are  fixed  and  staring 
or  strongly  turned  upward;  the  body  rigid,  and  the  face  congested.  The 
convulsion  is  at  first  tonic,  so  that  respiration  is  suspended,  but  presently 
clonic  convulsions  set  in,  the  eyes  are  moved  from  side  to  side,  there  are 
violent  twitchings  or  alternate  flexions  and  extensions  of  the  limbs,  contor- 
tion of  the  face,  and  retraction  of  the  head.  There  is  spastic  flexion  of  the 
fingers,  the  thumb  being  against  the  palm — clenched  fingers.  These  move- 
ments gradually  cease  $nd  the  child  passes  into  a  condition  of  stupor. 
There  is  usually  slight  elevation  of  temperature.  Convulsions  arising  from 
indigestion  and  those  which  usher  in  an  infectious  disease  are  commonly 
single,  but  those  due  to  rickets  recur  in  series.  In  some  instances  one 
attack  succeeds  another  until  death  ensues. 

When  the  attack  occurs  in  a  healthy  child,  it  may  be  due  to  acute 
indigestion  or  some  form  of  peripheral  irritation;  when  accompanied  by 
high  fever  and  vomiting  it  may  be  the  forerunner  of  an  acute  infection,  as 
scarlet  fever,  or  of  infantile  hemiplegia;  when  it  occurs  in  badly  nourished 
or  rickety  children  it  is  apt  to  be  incomplete  and  to  recur.  The  convulsions 
of  infancy  do  not  of  necessity  run  on  into  epilepsy,  but  general  convulsions 
occurring  without  apparent  cause  at  irregular  intervals  in  young  children 
otherwise  healthy  are  in  a  limited  proportion  of  the  cases  epileptic  from  the 
beginning. 

Ursemic  convulsions  may  be  preceded  by  headache  and  restlessness. 
Sometimes  they  come  on  without  warning.     The  epileptic  cry  does  not 


SYMPTOMS  AND  SIGXS:   CONVULSIONS.  607 

occur,  but  in  other  respects  the  attack  may  resemble  true  epilepsy.  The 
convulsions  are  often  recurrent  and  prolonged,  the  seizures  being  separated 
by  periods  of  coma  or  deep  stupor.  The  temperature  is  usually  subnormal; 
exceptionally  it  is  elevated.  The  condition  is  recognized  by  the  characters 
of  the  urine,  the  presence  of  oedema,  the  condition  of  the  heart  and  arteries, 
a  urinous  odor,  and  the  history  of  the  case. 

Puerperal  convulsions  present  the  same  clinical  picture  as  those  which 
occur  in  ordinary  nephritis. 

Hysterical  convulsions  are  to  be  distinguished  from  epilepsy  by  the 
emotional  state  which  precedes  the  attack,  the  globus  hystericus,  the  diffi- 
cult respiration,  the  alternating  laughter  and  tears.  Sensations  may  be 
described  which  suggest  the  epileptic  aura,  as  precordial,  abdominal,  or 
pelvic  uneasiness  or  distress.  The  patient  does  not  fall  to  the  floor  in  instant 
and  complete  unconsciousness  as  in  epilepsy,  but  gently  or  by  preference 
upon  a  sofa  or  couch  in  such  a  way  as  to  do  herself  no  harm.  The  move- 
ments are  irregular  and  clonic  but  usually  much  less  violent  than  in  epi- 
lepsy. The  tongue  is  not  bitten.  The  attack  gradually  subsides  and  the 
patient  becomes  conscious  and  emotional  again.  At  the  close  of  the  attack 
a  large  amount  of  light-colored  urine  of  low  specific  gravity  is  often  voided. 
The  more  violent  convulsions,  manifestations  of  hystero-epilepsy,  include 
grinding  of  the  teeth,  tonic  spasm,  opisthotonus,  and  other  forced  attitudes, 
clonic  spasms,  and  more  or  less  profound  unconsciousness.  The  attack  is 
more  prolonged  than  in  epilepsy  and  is  followed  by  contortions  and  cata- 
leptic poses  and  in  some  instances  by  attitudinizing  suggestive  of  various 
passionate  states. 

In  tetanus  the  earliest  symptoms  are  slight  stiffness  of  the  neck  and 
some  embarrassment  in  mastication.  These  symptoms  gradually  increase 
until  the  condition  of  trismus  or  lockjaw  develops.  The  spasm  extends 
and  involves  the  muscles  of  the  body,  causing  the  rigid  attitudes  known  as 
opisthotonus,  orthotonus,  pleurotonus,  and  emprosthotonus.  Respiration 
is  interfered  with  by  the  muscular  spasm  and  asphyxia  may  threaten  from 
closure  of  the  glottis.  The  convulsive  paroxysms  are  excited  by  the  slight- 
est irritation  and  are  of  variable  duration.  Complete  relaxation  may  not 
occur  during  the  intervals.    There  is  usually  a  history  of  trauma. 

The  resemblance  of  strychnine  poisoning  to  tetanus  is  close.  Trismus 
is  absent  as  a  rule  and  the  relaxation  between  the  convulsive  paroxysms 
is  complete.    There  is  a  history  of  the  ingestion  of  the  poison. 

Tetany  is  characterized  by  the  peculiar  position  of  the  hands  and  feet, 
the  involvement  of  the  extremities,  less  often  the  face  and  neck,  and  the 
presence  of  Trousseau's  symptom — the  reproduction  of  the  paroxysm  by 
compression  of  the  affected  part  either  in  the  direction  of  the  principal 
nerve-trunks  or  over  the  blood-vessels;  or  of  Chvostek's  symptom — an 
increase  in  the  mechanical  irritability  of  the  motor  nerves,  a  slight  tap 
over  the  nerve-trunk  being  sufficient  to  throw  the  muscles  into  active  spasm. 
The  history  of  the  case  is  quite  different  from  that  of  both  tetanus  and 
strychnine  poisoning. 


608  MEDICAL  DIAGNOSIS. 


TREMOR. 


Tremor  is  a  rhythmical  to-and-fro  movement  of  limited  range  due  to 
the  alternate  contraction  and  relaxation  of  opposing  muscles.  The  move- 
ments are  involuntary  and  differ  from  fibrillation  in  that  they  cause  loco- 
motion of  the  parts  involved.  It  is  due  to  nutritive  alterations  in  the  motor 
neurons  both  of  the  cortex  and  spinal  cord.  A  distinction  is  made  between 
intention  or  volitional  tremor,  which  shows  itself  only  upon  intentional  move- 
ments, and  passive  tremor,  which  occurs  when  the  parts  are  at  rest.  The 
former  is  sometimes  spoken  of  as  paralytic;  the  latter  as  spastic  tremor. 
In  the  examination  the  patient  is  to  be  observed  at  rest,  in  intentional 
movement,  and  in  attitudes  which  require  sustained  tonic  contraction  of 
the  muscles,  as  horizontal  extension  of  the  arms  and  hands,  separation  of 
the  fingers,  or  protrusion  of  the  tongue. 

The  following  forms  of  tremor  are  of  diagnostic  importance: 

1.  The  Intention  Tremor  of  Multiple  Sclerosis. — This  form  of 
tremor  does  not  occur  during  rest,  but  shows  itself  upon  intentional  move- 
ment, usually  at  first  slight,  then  progressively  more  rapid  and  with  wider 
oscillations,  so  that  the  intended  movement  is  greatly  hindered.  The 
movements  in  some  cases  are  so  great  and  so  irregular  as  to  suggest  ataxia. 
The  rate  of  the  tremor  in  disseminated  sclerosis  is  given  by  Peterson  at 
7.9  to  8.1  per  second  for  the  earlier  stages  and  4.6  to  6.3  for  the  later  stages. 

2.  The  tremor  of  paralysis  agitans  is  distinctly  slower.  It  con- 
tinues during  rest,  becomes  less  marked  upon  movement,  and  upon  deter- 
mined impulse  of  the  will  may  disappear  for  a  brief  period.  The  rate  is 
from  3  to  6  per  second.  This  form  of  tremor  disappears  during  sleep.  It 
usually  first  appears  in  the  hands  and  is  characterized  by  rhythmical 
movements  of  the  index  finger  against  the  thumb  which  suggest  pill  rolling. 
The  tremor  of  paralysis  agitans  very  seldom  affects  the  head. 

3.  Senile  tremor  is  in  its  more  moderate  forms  an  intention  tremor; 
in  well  developed  forms  a  tremor  of  rest.  The  hands  and  arms  are  more 
commonly  involved,  but  the  head  is  often  affected  and  the  under  jaw  and 
lips.    The  rate  is  from  4  to  6  oscillations  per  second. 

4.  The  tremor  of  exophthalmic  goitre  is  best  manifested  in  the 
hands  when  extended  and  the  fingers  separated.  It  sometimes  affects  the 
head.  The  rate  is  rapid — 8  or  more  per  second — and  the  excursion  limited. 
Upon  intentional  movements  the  tremor  is  sometimes  increased.  This 
form  of  tremor  is  common  in  hysteria,  in  which,  however,  every  form 
may  be  encountered.  It  is  seen  also  in  tuberculous  meningitis,  in 
lesions  of  the  corpora  quadrigemina,  and  rarely  in  disease  of  the  cere- 
bellum. Similar  tremors  occur  in  the  acute  febrile  diseases.  The 
tremor  of  enteric  fever  is  an  example.  It  occurs  even  in  mild  cases  and  is 
most  noticeable  in  the  tongue  when  it  is  protruded  for  examination.  At 
first  fine,  it  becomes  coarser  as  the  exhaustion  increases.  The  lips  are 
affected  and  in  severe  cases  the  hands.  It  is  more  marked  in  persons  who 
are  addicted  to  alcohol.  Murchison  regarded  excessive  tremor  as  one  of 
the  signs  of  deep  ulceration  of  Peyer's  patches. 

5.  The  toxic  tremors  are  usually  fine.  They  are  intensified  upon 
intentional  movement.     The  more  common  causes  are  alcohol,  tobacco, 


SYMPTOMS  AND  SIGNS:   FIBRILLATION.  609 

morphine,  and  mercury.  In  alcoholic  tremor  first  the  hands  and  then  the 
lips  are  affected,  and  it  is  temporarily  intensified  upon  the  withdrawal  of 
alcohol  and  diminished  by  its  administration  in  increased  doses. 

6.  Tremor  due  to  miscellaneous  causes,  as  intense  emotion,  exces- 
sive or  prolonged  muscular  effort  and  extreme  cold  may  occur  in  health}'' 
persons  and  is  without  diagnostic  importance.  Popular  phrases  are  trem- 
bling with  anger  or  fear  or  cold,  and  buck  fever,  in  the  inexperienced  hunter. 

FIBRILLARY  TWITCHING  OR  FIBRILLATION. 

This  is  an  involuntary,  brief,  sluggish  contraction  of  groups  of  muscular 
fibres  rather  than  of  an  entire  muscle.  It  is  manifested  as  a  wave-like 
movement  of  feeble  intensity  just  under  the  skin,  not  involving  the  muscle 
as  a  whole  and  producing  no  movement  of  the  parts  to  which  the  muscle 
is  attached.  It  may  occur  in  a  limited  number  of  fibres  at  long  intervals, 
or  in  successive  groups  of  fibres  in  rapid  succession.  There  are  cases  in 
which  fibrillary  contractions  do  not  occur  spontaneously  but  can  be  excited 
by  tapping  the  skin  overlying  the  muscle  with  the  finger,  and  in  those  cases 
in  which  they  occur  infrequently  they  may  be  produced  in  the  intervals  by 
the  same  manoeuvre.  They  often  occur  in  healthy  persons  upon  exposure 
of  the  surface  of  the  body  to  cold  air.  Fibrillation  is  probably  caused  by 
a  lesion  which  at  once  weakens  and  irritates  the  cell-body  of  the  peripheral 
motor  neuron  in  the  anterior  horn  of  the  spinal  cord  (Lloyd).  It  is,  there- 
fore, symptomatic  of  progressive  degenerative  processes  involving  and  gradu- 
ally destroying  the  large  ganglionic  motor  cells,  and  occurs  in  paretic 
and  atrophic  muscles  when  those  changes  are  of  nuclear  origin.  This  phe- 
nomenon is  especially  seen  in  anterior  poliomyelitis  and  in  bulbar  paralysis. 
It  may  be  present  in  traumatic  neuroses  without  paresis  or  atrophy. 

Other  morbid  motor  phenomena  are  discussed  in  the  chapter  upon 
the  Examination  of  the  Nervous  System. 


XV. 

PSYCHICAL  CONDITIONS,  EMOTIONAL  STATES,  DERANGE- 
MENTS OF  CONSCIOUSNESS,  INSOMNIA  AND 
OTHER   DISORDERS  OF  SLEEP. 

PSYCHICAL  CONDITIONS. 

The  consideration  of  abnormal  mental  phenomena  comes  properly 
within  the  scope  of  psychiatry.  Mental  derangements  constitute  at  times, 
however,  important  symptoms  in  almost  every  department  of  internal 
medicine.  The  degree  of  intelligence,  defects  of  memory,  emotional 
Btates,  and  irritative  and  depressive  derangements  of  consciousness  are 
to  be  considered.    Closely  allied  are  insomnia  and  other  disorders  of  sleep. 

Intelligence. — The  age,  education,  and  social  surroundings  of  the 
patient  are  to  be  considered.     Derangements  of  intelligence  are  frequently 

39 


610  MEDICAL  DIAGNOSIS. 

associated  with  impaired  consciousness  but  may  occur  independently  of  it. 
Both  vary  greatly  in  degree.  Slight  intellectual  defects  often  not  recognized 
m  the  ordinary  demeanor  and  conversation  of  the  patient  become  apparent 
upon  further  knowledge  or  upon  taking  a  careful  clinical  history.  The 
lower  grades,  designated  by  such  terms  as  dulness  and  stupidity,  or  an 
extreme  degree,  as  idiocy  and  dementia,  are  immediately  apparent  in  the 
facial  expression  and  behavior  of  the  individual.  Not  infrequently  a  fall- 
ing off  in  intelligence  is  manifest  in  persons  suffering  from  chronic  incurable 
affections,  as  valvular  disease  of  the  heart,  nephritis,  tuberculosis,  and  cancer. 
Not  only  is  the  nutrition  of  the  cerebral  cortex  impaired  but  the  patient's 
range  of  thought  becomes  progressively  more  circumscribed.  His  interest 
in  general  affairs  or  the  particular  objects  of  his  previous  intellectual  activity 
diminish  in  proportion  as  his  interest  in  his  symptoms  and  in  the  narrow 
life  of  the  sick-room  increase.  Graver  derangements  amounting  to  abso- 
lute indifference,  stupidity,  or  dementia  are  on  the  other  hand  observed 
in  cerebral  diseases,  especially  in  tumors  of  the  brain,  progressive  bulbar 
paralysis,  multiple  sclerosis,  hemorrhage,  thrombosis,  embolism,  and  soften- 
ing. In  other  cases  stupidity  or  dementia  may  be  the  expression  of  a 
developmental  anomaly  of  the  brain,  as  in  idiocy  and  cretinism.  Of  special 
interest  is  the  derangement  of  intelligence  which  occurs  in  myxcedema, 
both  that  form  which  develops  spontaneously  and  in  the  cachexia  strumi- 
priva.  In  this  condition,  which  is  closely  allied  to  cretinism  or  indeed 
practically  identical  with  it,  the  derangements  of  intelligence  vary  in  degree 
from  moderate  apathy  and  indifference  with  slowness  of  thought  associated 
with  slowness  of  speech  to  a  state  bordering  upon  dementia.  A  transient 
abnormal  exaltation  in  mental  activity  with  a  rapid  flow  of  ideas  and  un- 
usual facility  of  expression  may  attend  hectic  fever,  the  action  of  alcohol, 
and  excitement  due  to  other  causes.  A  corresponding  depression  in  mental 
activity  is  observed  in  the  period  of  reaction.  The  patient  who  has  been 
restless  and  talkative  in  the  febrile  period  is  depressed  and  silent  during  the 
sweating  that  attends  the  defervescence;  the  exhilaration  of  alcohol  is 
followed  by  the  depression  of  a  physical  if  not  a  moral  remorse;  fervor  of 
speech  and  energetic  action  give  place  to  dulness  and  abstraction. 

Mental  dulness  or  confusion  occurs  independently  of  derangements  of 
consciousness.  Confusion 'of  thought  attends  grave  neurasthenia,  cerebral 
tumor,  arteriocapillary  sclerosis,  old  age,  and  profound  malnutrition. 
Slowness  of  apprehension  and  unreadiness  in  expression  are  usually  char- 
acteristic of  defective  intelligence,  but  may  indicate  lesions  of  the  nervous 
mechanism  by  which  ideas  are  received  and  expressed,  as  in  forms  of  aphasia. 

Memory. — As  age  increases  the  memory  becomes  less  accurate  and 
retentive.  In  many  old  people  in  other  respects  in  good  health  and  intelli- 
gence failure  of  memory  becomes  pronounced.  At  earlier  periods  of  life 
the  integrity  of  the  memory  is  dependent  upon  the  same  conditions  of 
general  good  health  as  that  of  the  intelligence.  We  find  therefore  very  often 
impairment  or  loss  of  memory  in  local  lesions  of  the  brain  such  as  result 
from  hemorrhage  or  softening,  which  are  not,  however,  necessarily  asso- 
ciated with  enfeeblement  of  intelligence.  Weakness  of  memory  is  very 
often  observed  in  the  traumatic  neuroses — a  fact  demanding  attention 
since  frequently  this  condition  is  attributed  to  malingering.     Individuals 


.SYMPTOMS  AND  SIGNS:   EMOTIONAL  STATES.  611 

recovered  from  severe  traumatic  neurasthenia  very  often  have  but  faint 
recollection  of  the  events  associated  with  and  following  the  injury.  Loss 
of  memory  occurs  in  epilepsy,  bromidism,  and  chronic  alcoholism,  is 
common  in  insanity,  and  often  complete  in  terminal  dementia. 

EMOTIONAL   STATES. 

Mental  depression  is  very  common  in  chronic  and  incurable  diseases. 
It  is  sometimes  purely  symptomatic.  More  commonly  it  arises  from  pain 
and  suffering  or  from  apprehension  in  regard  to  the  future.  A  high  grade 
of  depression  characterizes  hypochondriasis  and  melancholia.  In  deep 
jaundice,  especially  when  chronic,  depression  is  very  common.  Mental 
depression  frequently  attends  diseases  of  the  stomach,  particularly  those 
in  which  pain  is  prominent.  Periods  of  depression  occur  during  the  meno- 
pause and  in  pronounced  neurasthenia,  hysteria,  and  in  cerebral  disease. 

Emotional  exaltation  characterizes  acute  and  chronic  mania  and  is 
an  important  element  in  active  delirium.  During  anaesthesia  by  chloro- 
form, ether,  and  nitrous  oxide  the  early  derangement  of  consciousness  is 
manifest  by  emotional  excitement  which  is  often  intense.  A  similar  condi- 
tion is  characteristic  of  alcoholic  intoxication. 

Instability  of  temper,  irritability,  and  sensitiveness  are  very  common 
in  invalids.  The  testiness  and  outbursts  of  anger  which  occur  in  gout 
and  the  fretfulness  and  impatience  of  uterine  disease  are  well  known. 
Emotional  instability  and  similar  changes  in  disposition  are  frequently 
observed  in  pregnancy. 

DERANGEMENTS   OF   CONSCIOUSNESS. 

These  may  be  irritative  or  depressive.  Irritative  derangements  of 
consciousness  vary  in  degree  from  mild  emotional  excitement  to  furious 
homicidal  mania;  in  extent  from  perversion  in  a  limited  region  of  con- 
sciousness relating  to  a  single  idea  or  group  of  ideas  to  systematized  delu- 
sions influencing  the  whole  life  of  the  patient.  Irritative  frequently  alter- 
nate with  depressive  derangements  of  consciousness.  Delusions,  illusions, 
and  hallucinations  are  irritative  derangements  of  consciousness. 

A  delusion  is  an  unfounded  conviction  or  belief.  It  is  very  often  ab- 
surd or  ridiculous.  Delusions  that  are  persistent  and  based  upon  false 
ideas  having  a  logical  interdependence  or  sequence  are  known  as  organized. 
An  expansive  delusion  is  an  insane  belief  in  the  individual's  own  greatness, 
power,  or  goodness.  No  evidence  or  demonstration  is  sufficient  to  convince 
a  person  of  the  falsity  of  his  delusions.  Examples  of  delusions  that  are 
common  are  the  belief  that  individuals,  almost  always  unknown,  are  con- 
spiring to  do  the  patienl    a  serious  harm,  or  that    the  patient    is  the  Christ 

or  Solomon  or  Queen  Victoria. 

An  illusion  is  a  false  or  misinterpreted  sensory  perception.  The  phe- 
nomena upon  which  it  is  based  actually  exist.  A  patient  who  mistakes  the 
nurse  for  an  officer  of  the  law,  or  a  bundle  of  rags  for  her  baby,  or  ordinary 

household  sounds  for  the  voice  of  God  IS  the  subject  of  an  illusion.  Illu- 
sions are  very  often   transient  or  momentary. 


612  MEDICAL  DIAGNOSIS. 

An  hallucination  is  a  sense  perception  not  founded  on  objective  reality. 
Hallucinations  may  relate  to  any  of  the  senses.  The  patient  who  sees  the 
figures  of  bystanders  or  hears  whispering  voices,  or  perceives  a  disagreeable 
odor  or  unpleasant  taste,  or  feels  upon  his  shoulder  the  pressure  of  a  hand 
when  none  of  these  objects  exist,  suffers  from  an  hallucination.  Hallucina- 
tions are  frequently  persistent  and  distressing. 

The  Obsessions. — An  obsession  is  an  idea  which  dominates  conscious- 
ness often  to  the  exclusion  of  other  thoughts  and  ideas.  It  comes  unbidden 
and  cannot  be  dismissed  by  any  effort  of  the  will.  Nevertheless  its  nature 
and  unreasonableness  are  usually  fully  understood  by  the  subject. 

Obsessions  very  commonly  take  the  form  of  definite  systematized 
fears  relating  to  certain  objects  or  conditions.  These  constitute  the 
so-called  phobias,  as  kenophobia,  the  dread  of  large  or  open  spaces; 
claustrophobia,  the  fear  of  closed  or  narrow  spaces;  agoraphobia  (ayopd, 
a  market  place),  the  fear  of  a  crowd;  aichmo phobia,  the  fear  of  pointed 
instruments  or  weapons  or  the  dread  of  being  touched  by  anything; 
■metallo  phobia,  a  terror  of  touching  or  handling  a  metallic  object;  pyrho- 
phobia,  a  morbid  dread  of  fire;  and  many  other  forms  of  persistent  and 
dominating  fear. 

Doubt  constitutes  a  common  form  of  obsession.  The  mental  uncer- 
tainty may  be  restricted  to  a  single  subject  or  set  of  subjects  or  embrace 
almost  every  affair  of  life  from  the  simplest  to  the  most  important,  recur- 
ring with  intolerable  insistence  and  refusing  to  be  allayed  by  the  demon- 
stration of  the  actual  conditions  to  which  they  relate. 

Another  group  of  obsessions  consists  in  a  morbid  exaggeration  of  the 
activities  of  life.  Those  who  are  subject  to  them  are  possessed  of  a  demon 
of  unrest  and  are  irresistibly  impelled  to  be  continually  doing  something  or 
going  somewhere,  usually  aimlessly  and  without  fixed  purpose,  and  always 
ready  without  adequate  motive  to  change  from  one  occupation  to  another 
or  from  the  selected  course  to  a  different  one. 

Closely  allied  to  this  group  of  obsessions  are  those  which  consist  in  an 
irritable  impulse  to  touch  a  spot  or  an  object — folie  de  toucher — or  to  repeat 
certain  movements,  as  returning  to  pass  through  a  door  two  or  three  times 
before  departing  from  it,  and  the  like. 

Fixed  ideas  are  closely  allied  to  obsessions  and  the  terms  are  often  used 
interchangeably.  There  are  those,  however,  who  distinguish  between  these 
two  derangements  of  consciousness,  namely,  that  an  obsession  is  recog- 
nized by  the  patient  as  an  abnormal  train  of  ideas  without  basis  in  fact, 
while  the  subject  of  a  fixed  idea  is  convinced  that  it  is  based  upon  the 
conditions  as  they  exist  and  perfectly  normal  under  the  circumstances. 

The  foregoing  derangements  of  consciousness  are  permanent  symp- 
toms in  insanity.  They  occur  also  in  hysteria  and  neurasthenia  and  con- 
stitute important  elements  of  delirium. 

Delirium  is  an  irritative  derangement  of  consciousness  characterized 
by  restlessness,  excitement,  and  incoherence.  Periods  of  delirium  may 
alternate  with  somnolence,  stupor,  or  convulsions.  There  are  two  forms  of 
delirium.  In  the  active  or  maniacal  the  patient  is  wild  and  noisy.  He 
sings,  screams,  shouts,  tries  to  get  out  of  bed,  struggles  with  his  attendants, 
and  has  to  be  restrained  by  force.     His  "face  is  congested,  his  eyes  bright, 


SYMPTOMS  AND  SIGNS:   DELIRIUM.  613 

his  expression  alert,  excited,  even  fierce.  The  second  form  is  low  or  mutter- 
ing. The  patient  lies  quiet,  murmuring  in  a  low  tone,  holding  incoherent 
and  often  whispered  conversation  with  imaginary  persons,  or  occupied  with 
vague  fancies  and  taking  no  notice  of  what  goes  on  around  him.  If  aroused 
he  may  give  a  rational  but  brief  reply  to  questions,  quickly  relapsing  into 
his  wandering  dreams.  This  form  of  delirium  is  sometimes  associated  with 
restlessness.  The  patient  moves  in  bed,  may  even  try  to  get  up,  but  is 
easily  restrained.  Between  these  two  there  are  transitional  forms  attended 
with  moderate  restlessness  and  excitement.  The  patients  are  irritable, 
disturbed  by  trifles,  and  at  times  incoherent,  though  not  boisterous. 

Delirium  develops  very  readily  in  persons  of  neurotic  temperament 
and  in  early  life.  It  may  occur  in  any  severe  illness.  It  is  especially  com- 
mon in  fever  and  usually  indicates  a  grave  infection.  In  febrile  diseases 
children  are  more  liable  to  delirium  than  adults,  just  as  they  are  more 
liable  to  high  temperature.  In  general  terms,  there  is  no  constant  relation 
between  particular  diseases  and  forms  of  delirium.  Active  delirium  is, 
however,  frequently  associated  with  the  acute  infectious  fevers.  The 
delirium  of  pneumonia  is  sometimes  violent;  in  inflammatory  diseases  of 
the  brain  and  in  acute  mania  it  is  often  furious.  In  fevers  of  ordinary 
intensity  the  delirium  is  of  moderate  type.  It  is  muttering  or  wandering  in 
the  exhaustion  of  the  low  fevers  and  in  the  later  stages  of  other  acute  dis- 
eases. Delirium  may  be  present  in  uraemia  and  in  poisoning  by  belladonna, 
cannabis  indica,  hyoscyamus,  and  opium,  and  a  loud  and  boisterous  delirium 
quite  different  from  delirium  tremens  sometimes  occurs  in  acute  alcoholism. 
In  enteric  fever  the  headache  usually  ceases  as  delirium  develops. 

The  onset  of  delirium  may  be  abrupt  or  gradual.  An  outbreak  of 
maniacal  delirium  has  in  rare  instances  been  the  first  manifestation  of  an 
acute  infectious  disease,  as  enteric  fever,  typhus,  or  pneumonia.  Cases  have 
occurred  in  which  under  these  circumstances  individuals  have  been  regarded 
as  insane  and  placed  in  an  asylum.  Much  more  commonly  delirium  de- 
velops gradually,  showing  itself  first  in  a  certain  confusion  of  thought  upon 
awaking  from  sleep.  In  some  cases  delirium  is  absent  during  the  day, 
coming  on  again  and  increasing  as  night  approaches.  Mild  nocturnal 
delirium  is  sometimes  seen  during  convalescence  from  pneumonia,  enteric 
fever,  and  septic  conditions. 

The  delirium  of  inanition  occurs  in  wasting  diseases  and  in  starvation. 
It  is  not  very  rare  in  malignant  disease  of  the  oesophagus  or  stomach  and 
occurs  in  cases  characterized  by  intractable  vomiting.  The  delirium  of 
convalescence  is  probably  a  delirium  of  inanition.  In  this  form  of  delirium 
the  outbreak  is  sudden,  usually  in  the  early  morning.  There  is  feebleness 
of  pulse  and  a  relaxed  and  sweating  skin  with  cold  hands  and  feet.  It  is 
very  often  of  brief  duration,  yielding  in  the  course  of  some  hours  or  a  day 
or  two  to  the  proper  administration  of  nourishment  and  stimulants.  Mani- 
acal delirium  not  uncommonly  follows  the  epileptic  paroxysm  — postepileptic 
mania — or  may  develop  as  the  psychical  equivalent  of  the  paroxysm. 

The  delirium  of  alcoholism-  -delirium  tremens— is  very  characteristic. 
It  is  almost  always  associated   with  hallucinations  which  take  the  form  of 

large  cumbers  of  small  objects,  as  mice,  bugs,  serpents  which  continually 
approach  the  patienl  and  inspire  abject  and  pitiable  terror,  or  there  are 
animals  running  around  his  bed  or  crawling  upon  the  walls.    The  delirium 


614  MEDICAL  DIAGNOSIS. 

is  busy.  The  patient  is  restless,  his  hands  are  constantly  moving,  he  tries 
to  get  out  of  bed,  but  is  usually  tractable.  Associated  symptoms  of  diag- 
nostic importance  are  tremor  and  sleeplessness,  which  are  almost  constantly 
picsent.  A  condition  not  unlike  delirium  tremens  may  develop  in  other 
drug  habits.  It  has  been  observed  after  prolonged  excesses  in  morphine, 
chloral,  and  paraldehyde. 

Carphologia,  literally  a  gathering  of  chaff,  the  picking  at  the  bed- 
clothes, seen  in  the  wandering  delirium  of  grave  fevers  and  profound 
exhaustion,  is  of  unfavorable  prognostic  significance.  The  patients  lie 
quiet,  wholly  oblivious  of  their  surroundings,  plucking  with  feeble  hands 
at  the  bed-covering  or  grasping  at  imaginary  objects  in  the  air.  These 
movements  are  dependent  upon  hallucinations. 

Delirium  is  sometimes  simulated  by  malingerers.  Feigned  delirium 
is  to  be  recognized  by  the  absence  of  other  signs  of  illness,  the  want  of  the 
characteristic  incoherence,  and  by  the  continuing  sameness  and  limited 
range  of  the  manifestations. 

Depressive  derangements  of  consciousness  vary  in  degree  from  simple 
clouding  of  the  ordinary  consciousness  to  complete  unconsciousness.  They 
affect  the  entire  field  of  consciousness.  Loss  of  consciousness  may  be  sud- 
den or  gradual,  and  is  a  symptom  of  great  diagnostic  importance. 

Somnolence  is  the  term  used  to  describe  the  mildest  degree.  The 
individual  is  dull,  drowsy,  and  indifferent,  but  retains  an  appreciation  of 
his  surroundings  and  can  respond  more  or  less  intelligently  when  addressed. 
Naturally  there  is  no  sharp  line  of  demarcation  between  this  and  the  fol- 
lowing progressive  conditions. 

Sopor,  literally  a  sound  or  deep  sleep,  constitutes  a  more  profound 
impairment  of  consciousness.  The  individual  lies  deeply  drowsy  and  indif- 
ferent to  his  surroundings  but  can  be  aroused.  To  questions  he  replies  in 
monosyllables  and  when  aroused  can  move  himself  about  and  has  a  con- 
fused notion  of  his  surroundings.  Left  to  himself  he  sinks  again  into  an 
abnormal  drowsiness  attended  with  muttering  or  snoring. 

Stupor  is  partial  or  nearly  complete  unconsciousness.  The  patient 
cannot  be  aroused  except  with  difficulty  and  then  replies  reluctantly  and 
briefly  to  questions,  relapsing  at  once  into  his  previous  condition.  The  ex- 
pression of  the  face  is  dull  and  "stupid."    He  is  still  capable  of  swallowing. 

Coma  is  complete  loss  of  consciousness.  The  patient  cannot  be  aroused 
from  his  insensibility.  Perception  and  volition  are  wholly  suspended. 
The  face  is  expressionless,  the  respiration  stertorous,  the  mouth  open,  the 
tongue  dry.  Swallowing  is  impossible,  the  sphincter  ani  is  relaxed,  there 
is  urinary  incontinence  or  retention.  The  breathing  is  frequently  irregular. 
It  may  be  irregularly  interrupted  or  show  the  Cheyne-Stokes  modification. 

Coma  vigil  is  a  condition'  of  profound  unconsciousness  attended  by 
muttering  delirium  and  carphologia.  It  is  characteristic  of  this  condition 
that  the  eyes  are  open  and  appear  to  follow  the  movements  of  the  attend- 
ants.   The  prognosis  is  ominous. 

Syncope — a  swoon  or  fainting — is  a  sudden  loss  of  consciousness, 
usually  complete  and  transient,  associated  with  pallor,  coolness  of  the  skin, 
and  muscular  prostration.  It  is  a  manifestation  of  acute  anaemia  of  the 
brain  resulting  from  failure  of  the  heart's  action.  It  may  be  caused  in 
neurotic  persons  by  sudden  violent  depressing  emotions,  as  fear  or  horror. 


SYMPTOMS  AND  SIGNS:   COMA.  bio 

or  follow  intense  or  prolonged  muscular  effort,  or  accompany  hemorrhage 
or  shock.  It  is  important  in  all  cases  to  make  the  differential  diagnosis 
between  suddenly  on-coming  coma  and  syncope. 

Lethargy  or  trance  is  a  condition  of  unconsciousness,  more  or  less 
complete,  which  occurs  in  hysteria.  It  has  been  observed  in  rare  instances 
after  excessive  mental  application  or  exhausting  disease  and  cases  have 
been  noted  in  which  it  has  occurred  in  individuals  otherwise  apparently 
in  good  health.  It  differs  from  coma  in  resembling  a  deep  and  protracted 
sleep  from  which  the  patient  in  some  instances  may  be  partially  aroused. 
The  patient  is  usually  pallid,  the  extremities  relaxed,  the  eyelids  closed, 
the  eyes  turned  upward  or  to  one  side.  The  pupils  vary  in  size  but  react 
to  light.  Respiration  and  circulation  are  greatly  enfeebled.  The  tem- 
perature is  subnormal.  The  attack  varies  in  duration  from  some  hours  to 
several  weeks.     Cataleptic  rigidity,  or  convulsions,  may  develop. 

Catalepsy  is  a  condition  of  impaired  consciousness  characterized  by 
rigidity  affecting  the  voluntary  muscles.  A  limb  or  the  body  of  the  patient 
may  be  maintained  continuously  for  some  time  in  the  same  posture.  The 
position  of  the  limb  may  be  passively  changed  with  slight  resistance, 
remaining  in  the  posture  in  which  it  has  been  placed.  This  condition  of 
increased  muscular  tonus  has  been  termed  "waxy  flexibility. "  The  attack 
may  last  for  a  few  minutes  or  for  several  hours.  It  is  attended  with  com- 
plete anaesthesia  of  the  skin  and  deeper  tissues.  The  rhythm  of  the 
respiration  is  disturbed,  the  circulation  feeble,  the  surface  temperature 
depressed,  and  the  reflexes  impaired.  The  eyes  are  usually  open;  the  pupils 
are  dilated  but  react  to  light.  The  attitudes  are  sometimes  bizarre  and 
grotesque.  As  the  attack  passes  away  the  power  of  muscular  movement 
is  fully  regained.  Catalepsy  is  a  rare  symptomatic  disorder.  It  is  encoun- 
tered in  hysteria,  occurs  in  hypnotic  states,  and  has  been  observed  in  cerebral 
disease,  as  tumor  and  meningitis,  and  in  forms  of  insanity,  as  melancholia. 

Coma  may  be  easily  recognized.  Its  diagnostic  significance  is  often 
obscure.  It  occurs  not  only  in  cerebral  disease  but  in  the  most  varied 
constitutional  conditions.     It  may  be  symptomatic  of  the  following: 

(a)  Organic  disease  of  the  brain,  either  general,  as  acute  encephalitis, 
cerebral  syphilis,  multiple  sclerosis,  and  general  paresis;  focal,  as  intra- 
cranial hemorrhage,  embolism,  thrombosis  or  softening,  tumor,  abscess 
and  thrombosis  of  the  cerebral  sinuses;  disease  of  the  meninges,  as  inflam- 
mation, the  pressure  from  exudate,  and  subdural  hemorrhage  or  tumor; 
or,  finally,  it  may  occur  in  the  course  of  disease  of  the  cranial  bones,  (b) 
Traumatism  of  the  head,  producing  cerebral  commotion  or  compression. 
(c)  The  pre-agonistic  state  in  all  diseases  terminating  fatally,  (d)  The  fully 
developed  febrile  infectious  diseases.  Only  exceptionally  is  coma  under 
these  circumstances  complete.  Early  and  complete  coma  occurs  in  the 
malignant  forms,  (e)  Uraemia,  in  which  it  commonly  alternates  with  con- 
vulsions, (f)  The  last  stage  of  diabetes,  (g)  Forms  of  auto-intoxication 
analogous  to  diabetic  coma  in  which  /?-oxybutyric  acid  or  its  derivatives  are 
present  in  the  blood,  (h)  Rare  cases  of  septicaemia,  pyaemia,  carcinoma,  and 
acute  yellow  atrophy  of  the  liver,  (i)  Narcotic  poisoning,  especially  by  alco- 
hol, morphine,  chloral,  and  various  poisonous  gases,  and  the  Burgical  anaes- 
thesia produced  by  the  administration  of  ether,  chloroform,  nitrous  oxide, 
etc.     (j)  General  convulsions,  infantile  eclampsia,  and  the  epileptic  par- 


616  MEDICAL  DIAGNOSIS. 

oxysm.  (k)  Drowning  and  asphyxia  from  other  causes.  (1)  Sunstroke  and 
similar  conditions  produced  by  exposure  to  excessive  heat,     (m)  Hysteria. 

The  Associated  Phenomena  in  Different  Morbid  States  Characterized  by 
Coma. — The  diagnosis  of  the  underlying  condition  is  always  important, 
often  difficult,  sometimes  impossible.  When  the  previous  history  can  be 
obtained  from  the  patient's  friends  the  diagnosis  is  simplified.  A  child  is 
seized  with  convulsions  and  vomiting  and  falls  presently  into  coma.  The 
fact  that  other  children  in  the  family  suffer  from  scarlet  fever  justifies  a 
provisional  diagnosis  of  malignant  scarlet  fever.  A  man  in  middle  life 
complains  of  headache  and  becomes  comatose,  with  twitching  of  the  face 
and  general  convulsions.  Information  to  the  effect  that  he  has  had  poly- 
uria with  low  specific  gravity,  small  amounts  of  albumin,  and  casts,  war- 
rants a  diagnosis  of  uraemia.  A  girl  is  found  unconscious,  pallid,  with 
irregular  respiration  and  occasional  twitching  of  the  face  or  extremities. 
It  is  of  diagnostic  importance  to  learn  that  she  has  been  a  highly  nervous 
person  who  has  just  passed  through  some  emotional  stress  and  that  the 
coma  was  preceded  by  tears  and  outbreaks  of  laughter — phenomena 
characteristic  of  hysteria. 

The  anamnesis  is  not  always  conclusive.  It  frequently  happens  that 
a  patient  suffering  from  chronic  nephritis  becomes  comatose  from  cerebral 
hemorrhage  and  that  a  man  who  has  been  drinking  falls  into  a  coma  not 
the  manifestation  of  alcoholic  intoxication  but  of  fracture  of  the  skull. 
The  causal  diagnosis  of  coma  is  attended  with  increased  difficulty  in  am- 
bulance cases  and  patients  concerning  whom  no  history  can  be  obtained, 
seen  for  the  first  time  in  a  comatose  condition. 

Cerebral  Disease. — Coma  occurring  in  the  course  of  organic  disease 
of  the  brain  is  usually  preceded  by  such  general  symptoms  as  headache, 
vomiting,  delirium,  and  somnolence,  with  varied  local  symptoms  which 
depend  upon  the  position  and  extent  of  the  lesions  and  may  be  either 
irritative  or  paralytic. 

Apoplexy — the  Apoplectic  Insult. — Premonitory  symptoms  are 
rare.  Headache,  ocular  derangements,  and  paresthesia  of  the  extremi- 
ties may  occur  but  are  not  characteristic.  The  coma  usually  is  sudden 
and  complete  and  the  condition  is  popularly  spoken  of  as  a  "stroke." 
In  other  cases  the  coma  develops  gradually — ingravescent  apoplexy. 

Traumatism  of  the  Head. — The  history  of  an  accident  or  injury  is 
important.  A  careful  examination  should  be  made  for  contusion,  lacera- 
tion, or  depression  of  the  skull.  If  necessary  the  head  should  be  shaved. 
Bleeding  from  one  or  both  ears  may  occur  in  fracture  of  the  base  of  the  skull. 

Infectious  Diseases. — The  antecedent  conditions  leading  up  to  the 
coma  are  usually  known.  Coma  under  these  circumstances  may  be  a 
manifestation  of  the  intensity  of  the  primary  infection  or  of  some  second- 
ary process.  Occasionally  in  grave  enteric  fever,  very  commonly  in  severe 
typhus  and  cerebrospinal  fever,  coma  develops  in  the  course  of  the  disease 
and  is  not  necessarily  the  sign  of  impending  dissolution.  Coma  may  occur 
under  similar  circumstances  from  an  intercurrent  nephritis  with  uraemia  or 
from  intercurrent  cerebral  hemorrhage,  sinus  thrombosis,  or  in  the  rheu- 
matic fever  attended  with  endocarditis  from  embolism.  Coma  occurs 
early  in,  or  may  even  mark  the  onset  of,  the  malignant  forms  of  the  infec- 
tious diseases,  particularly  scarlet,  enteric,  and  cerebrospinal  fever  and  the 


SYMPTOMS  AND  SIGNS:   COMA.  617 

pernicious  forms  of  malarial  infection.  In  the  last  there  is  the  history 
of  exposure  in  intensely  malarial  localities  and  of  one  or  two  recent  well 
characterized  paroxysms  of  ague. 

Uraemia. — Uraemic  coma  may  occur  in  acute  or  chronic  nephritis. 

Diabetes. — In  saccharine  diabetes  coma  very  often  attends  the  ter- 
minal condition,  particularly  in  the  young.  Three  forms  of  diabetic  coma 
are  recognized:  (a)  The  patient  after  exertion  is  seized  with  sudden  weak- 
ness, syncope,  and  somnolence  which  gradually  deepens  to  coma  and  is 
followed  in  a  few  hours  by  death,  (b)  The  early  symptoms  are  due  to  pul- 
monary or  gastric  derangement  or  there  may  be  some  local  affection,  as 
pharyngitis,  phlegmon,  or  carbuncle.  The  attack  begins  with  nausea  and 
vomiting.  The  breath  has  the  peculiar  sweetish,  fruity  odor  of  acetone. 
The  onset  of  coma  is  gradual.  Death  occurs  in  the  course  of  one  to  five  days. 
(c)  The  patient  without  special  previous  symptoms  is  suddenly  seized 
with  violent  headache  and  the  sensation  of  profound  illness  and  rapidly 
falls  into  deep  and  fatal  coma.  There  are  cases  of  diabetes  in  which  the 
coma  is  due  to  some  accidental  cause,  as  uraemia,  apoplexy,  or  meningitis. 

Narcotic  Poisoning. — In  coma  from  opium  and  its  derivatives  the 
face  is  pallid,  dusky,  and  slightly  cyanotic,  respirations  and  pulse  slow, 
pupils  equal  and  contracted,  skin  natural,  and  temperature  normal. 

In  alcoholic  coma  the  face  is  commonly  flushed,  sometimes  pallid, 
occasionally  cyanotic.  The  respirations  are  usually  normal  in  depth  and 
frequency.  They  are  sometimes  stertorous.  The  odor  of  the  breath  is 
characteristic,  the  pulse  is  at  first  frequent  and  full,  later  small  and  feeble. 
The  pupils  are  equal,  sometimes  normal,  more  frequently  dilated.  The 
skin  is  usually  cool  and  moist  and  the  surface  temperature  lowered,  espe- 
cially under  circumstances  of  exposure  to  cold  or  damp,  when  heat  dissipa- 
tion is  favored.     Convulsions  are  not  common. 

Poisonous  Gases. — Coma  develops  under  circumstances  that  make 
the  diagnosis  clear.  It  may  result  from  the  inhalation  of  carbon  dioxide, 
as  in  disused  wells,  and  carbon  monoxide — illuminating  gas,  charcoal  fire — 
a  very  common  cause  of  accidental  death  and  suicide.  There  can  be  no 
question  about  the  coma  of  surgical  anaesthesia.  During  this  state  various 
accidents  may  occur.  Asphyxia  has  resulted  from  the  falling  back  of  the 
base  of  the  tongue  and  from  pulmonary  oedema.  Progressively  deepening 
coma  may  terminate  in  death  from  failure  of  the  cardiac  or  respiratory 
centres,  and  apoplexy  may  occur. 

Convulsions. — Coma  is  very  often  preceded  by  general  convulsions 
<ir  alternates  with  them.  It  is  frequently  preceded  by  convulsions  in  the 
malignant  forms  of  the  infectious  diseases,  especially  in  children,  and 
sometimes  in  dentition  and  the  digestive  disorders  in  young  infants — 
infantile  eclampsia.  It  follows  the  general  convulsions  of  epilepsy.  Coma 
and  convulsions  may  alternate  in  cerebral  syphilis,  general  paresis,  and 
some  forms  of  alcoholism.  The  alternation  of  coma  and  convulsions  is 
characteristic  of  uraemia. 

The  coma  of  sunstroke  is  very  often  preceded  by  convulsions.  The 
skin  is  excessively  hoi  and  dry,  the  face  flushed,  the  respiration  labored, 
the  pulse  frequent  and  full.  The  temperature  ranges  extremely  high  and 
may  become  thai  of  hyperpyrexia.  Upon  venesection  the  blood  is  dark, 
thick,  ami  flows  slowly  from  the  vein.     The  diagnosis  is  usually  easy. 


618  MEDICAL  DIAGNOSIS. 

Epilepsy. — The  diagnosis  of  postepileptic  coma  rests  upon  the  history 
of  the  case,  the  convulsive  seizure,  the  bitten  tongue,  the  foam  upon  the 
lips,  and  the  sudden  profound  loss  of  consciousness  of  no  very  long  dura- 
tion. The  congestion  of  the  face,  stertorous  breathing,  urinary  incon- 
tinence, and  general  muscular  relaxation  may  suggest  apoplexy,  but  the 
signs  of  hemiplegia  are  lacking. 

Hysteria. — The  unconsciousness  of  hysteria  is  commonly  incomplete 
— lethargy  or  its  intensification,  trance.  Its  duration  may  extend  over 
several  clays  or  weeks.  True  hysterical  coma  which  is  a  further  intensifica- 
tion of  the  foregoing  is  very  rare.  A  condition  of  impaired  consciousness 
suggestive  of  coma  not  infrequently  enters  into  the  symptom-complex  in 
the  grand  attack  of  hysteria.  It  is  usually  preceded  by  the  ordinary 
phenomena  of  the  hysterical  paroxysm:  laughing,  crying,  convulsions, 
extravagant  muscular  movements,  and  the  like. 

For  practical  purposes  the  differential  diagnosis  between  the  coma 
resulting  from  opium,  traumatism,  alcohol,  apoplexy,  and  uraemia  is  of 
imperative  importance.  Only  in  a  correct  diagnosis  are  to  be  found  the 
indications  for  treatment.  These  are  often  immediate  and  urgent.  Further- 
more the  diagnosis  may  have  to  do  with  questions  of  medico-legal  interest. 
Definite  diagnostic  phenomena  are  to  be  systematically  sought  for. 

Such  points  in  the  anamnesis  as  are  available  are  to  be  obtained  from 
the  patient's  friends  or  the  bystanders.  The  immediate  investigation  de- 
mands an  examination  of  the  scalp  and  head  for  evidences  of  traumatism; 
of  the  eyes  with  reference  to  pupillary  conditions  and  reactions,  strabismus, 
and  conjugate  deviation;  the  face  for  blood  extravasations,  flushing, 
pallor,  cyanosis,  eedema,  puffing  of  the  cheeks,  the  presence  of  foam  upon 
the  lips,  a  bitten  tongue,  relaxation  of  the  jaw,  the  odor  of  the  breath, 
and  the  presence  upon  the  lips  or  face  of  the  stains  of  corrosive  or  other 
poisons.  The  character  of  the  respiration  is  to  be  studied,  the  frequency, 
volume,  and  tension  of  the  pulse,  the  sounds  of  the  heart.  The  occurrence 
of  fecal  or  urinary  incontinence  is  to  be  noted,  catheterization  should  be 
performed,  and  the  urine  examined  for  the  presence  of  albumin,  blood 
sugar,  acetone,  etc.  The  signs  of  hemiplegia  are  to  be  sought  in  the  posi 
tion  of  the  head  and  eyes— conjugate  deviation — in  the  greater  relaxation 
of  the  mouth  and  cheek  upon  one  side  and  the  complete  loss  of  muscular 
tonus  in  the  arm  and  leg.  The  temperature  must  be  taken  in  the  axilla, 
and  if  found  to  be  very  low,  in  the  rectum  also.  The  signs  of  antecedenl 
disease,  general  anasarca,  great  emaciation,  various  specific  and  othei 
eruptions  and  scars,  and  the  general  condition  of  the  viscera  as  determined 
by  the  methods  of  physical  examination,  such  as  the  presence  of  effusions 
in  the  serous  sacs,  great  enlargement  of  the  liver  or  spleen,  and  the  like,  are 
to  be  in  turn  rapidly  investigated.  The  stomach  pump  is  often  necessary 
for  the  diagnosis.  If  the  conditions  suggest  the  possibility  of  pernicious 
malarial  fever  an  examination  of  the  blood  should  be  made  for  Laveran's 
bodies. 

Not  every  case  demands  such  comprehensive  and  elaborate  investi- 
gation. Very  often  the  condition  underlying  the  coma  is  obvious  at  a 
glance.  In  other  cases  it  is  speedily  revealed.  Once  in  a  while  the  true 
condition  is  not  discovered  without  careful  and  prolonged  study,  and  there 
are  obscure  cases  which  tax  the  resources  of  clinical  medicine. 


SYMPTOMS  AND  SIGNS:   INSOMNIA.  619 

INSOMNIA  AND  OTHER  DISORDERS  OF  SLEEP. 

Insomnia — Abnormal  Wakefulness. — These  terms  are  used  to  desig- 
nate a  disturbance  of  the  nervous  system  characterized  by  habitual  incom- 
plete sleep  or  periods  of  entire  absence  of  normal  sleep.  Sleep  varies  with  age, 
sex,  and  individual  peculiarity.  In  very  young  babies  sleep  is  practically 
continuous;  a  healthy  child  two  years  old  passes  half  its  time  in  slumber; 
the  adult  requires  from  seven  to  eight  hours  out  of  twenty-four;  and  aged 
persons  not  more  than  five  or  six  hours.  Women  need  more  sleep  than 
men.  Workers  in  the  open  air  require  longer  hours  of  sleep  than  those  of 
sedentary  habits.  Insomnia  may  be  functional  or  symptomatic.  Func- 
tional insomnia  occurs  in  neurotic  individuals  and  over-taxed  brain  workers. 
Symptomatic  insomnia  is  an  important  element  in  the  symptom-complex 
of  a  great  variety  of  morbid  conditions.  It  occurs  in  painful  diseases,  as 
cancer,  aneurism,  and  the  intractable  neuralgias.  It  is  common  in  acro- 
msgaly.  Insomnia  is  a  very  troublesome  symptom  in  neurasthenia  and 
various  forms  of  insanity.  It  is  an  important  element  in  acute  delirium. 
Advanced  disease  of  the  heart  is  very  often  attended  by  sleeplessness  due 
in  part  to  cerebral  anaemia,  in  part  to  the  condition  of  the  blood,  but 
chiefly  to  the  inability  of  the  patient  to  lie  down.  As  the  condition  pro- 
gresses wakefulness  gives  way  to  somnolence  and  stupor.  Tea  and  coffee 
have  in  many  persons  the  power  of  inhibiting  sleep.  Complete  insomnia 
is  a  conspicuous  phenomenon  in  delirium  tremens  and  alcoholic  mania. 
Insomnia  occurs  with  some  degree  of  frequency  also  in  the  early  stage  of 
enteric  fever,  influenza,  and  croupous  pneumonia.  It  is  met  with  in  cases 
of  malaria  and  is  a  troublesome  symptom  in  trichiniasis.  It  is  not  un- 
common during  the  convalescence  from  acute  disease.  Insomnia  may 
take  the  form  of  troubled  and  unrefreshing  sleep  of  short  duration  or 
broken  by  intervals  of  distressing  wakefulness,  or  sleep  may  be  absent  for 
days  together.  The  patient  may  fall  asleep  upon  going  to  bed  but  awakes 
in  the  course  of  two  or  three  hours  and  lies  absolutely  awake  or  lightly 
dozes  until  morning.  There  is  often  great  and  irregular  mental  activity, 
especially  in  neurasthenia,  and  the  cares,  anxieties,  and  worries  of  the  day 
are  rehearsed  with  torturing  iteration.  Such  insomnia  is  associated  with 
restlessness,  which  is  also  present  in  the  insomnia  of  insanity.  Insomnia 
is  rare  in  children  but  when  present  significant  of  profound  disturbance  of 
the  nervous  system.  The  sleeplessness  of  the  aged  is  usually  tranquil  and 
unaccompanied  by  excitement  or  irritability. 

Dreams  usually  have  their  starting-point  in  some  sensory  impression 
arising  from  local  causes,  as  an  uncomfortable  posture,  a  sound  which  is 
perceived  but  which  does  not  arouse,  an  over  loaded  stomach,  a  distended 
bladder  or  rectum,  or  a  condition  which  interferes  with  the  action  of  the 
heart  and  lungs.  Nightmare  is  a  frightful  dream  accompanied  by  sensa- 
tions of  oppressive  weight  upon  the  chest,  intense  fear,  horror,  or  anxiety, 
and  inability  to  move  or  cry  out.  The  attack  ends  in  a  groan  and  the 
recovery  of  consciousness.     It  is  mostly  symptomatic  of  indigestion. 

Night  Terrors  Pavor  Nocturnus. — This  condition,  which  presents 
points  of  resemblance  to  nightmare  and  somnambulism,  is  a  paroxysmal 
disturbance  of  sleep  in  young  children.      It  differs  from  nightmare  in  the 


620  MEDICAL  DIAGNOSIS. 

gradual  subsidence  of  the  attack  and  the  persistence  of  terror  and  distress 
after  waking.  It  differs  from  somnambulism  in  the  gradual  waking,  the  less 
complete  automatism,  and  the  terror.  The  child  starts  up  in  bed  screaming 
with  fear  and  seeks  protection,  trembling  and  sobbing.  The  dream  images 
are  often  indefinite,  sometimes  the  creatures  of  imagination,  suggested  by 
the  tales  of  the  nursery.  Night  terrors  occur  commonly  in  neurotic  and 
badly  nourished  children.  They  are  sometimes  symptomatic  of  eye-strain, 
the  cutting  of  the  second  teeth,  intestinal  parasites,  or  indigestion. 

Sleep  drunkenness  is  a  rare  condition  resembling  maniacal  delirium 
which  appears  upon  waking  from  profound  sleep.  There  are  delusions  of 
immediate  danger  to  life  or  liberty.  The  sufferer  fails  to  recognize  his 
surroundings.  He  is  excited,  incoherent,  and  boisterous.  The  attack  is 
usually  of  short  duration. 

Somnambulism — sleep=walking — is  a  disorder  of  sleep  in  which  con- 
sciousness and  volition  are  suspended  but  the  activity  of  certain  nerve- 
centres  is  exerted  and  coordinated  movements  are  automatically  per- 
formed. It  occurs  in  adolescents  and  young  adults  of  neurotic  tempera- 
ment and  is  more  common  in  females.  It  is  due  to  causes  which  ordinarily 
give  rise  to  dreams,  including  indigestion,  faulty  attitude  during  sleep, 
intense  excitement,  or  violent  distressing  emotion  during  the  period  preced- 
ing sleep.  The  attacks  are  frequently  recurrent  and  may  become  habitual. 
They  are  of  brief  duration  but  may  continue  an  hour  or  two,  during  which 
time  difficult  and  complicated  actions  are  performed,  apparently  with 
conscious  intention.  The  eyes  are  closed  or,  if  open,  are  staring  and  fixed. 
There  is  complete  indifference  to  sound  and  the  expression  is  blank  and 
impassive.     The  patient  on  waking  has  no  recollection  of  his  wanderings. 

Morbid  Sleep. — Drowsiness  may  be  symptomatic  of  cerebral  malnutri- 
tion or  toxaemia.  It  is  common  in  aged  persons  with  feeble  heart  and  dis- 
eased blood-vessels,  in  the  obese,  and  in  malaria,  anaemia,  and  diabetes.  It 
is  caused  by  the  impure  air  of  crowded  assemblies.  Cases  have  been 
reported  in  which  prolonged  deep  sleep  has  ceased  after  the  discharge  of 
lumbricoid  worms.  Morbid  sleep  is  a  symptom  by  no  means  uncommon  in 
organic  cerebral  disease,  as  syphilis,  tumor,  and  arteriosclerosis.  It  is 
common  in  insanity,  both  in  the  prodromal  period  and  the  developed  state. 

Narcolepsy  is  abnormal  deep  sleep  occurring  in  spells  which  may  be 
of  short  duration  or  prolonged  and  continuous.  The  cause  is  unknown.  In 
some  instances  the  sleep  has  progressively  advanced  to  deep  and  fatal  coma. 

Waking  numbness — sleep  palsy. — This  is  a  form  of  parsesthesia  occur- 
ring upon  waking.  There  is  a  sensation  of  numbness  and  tingling.  The  dis- 
tribution involves  one  or  more  extremities,  usually  the  hands  and  arms.  It 
is  commonly  of  brief  duration,  disappearing  in  an  hour  or  two.  It  resembles 
the  forms  of  parsesthesia  which  occur  about  the  grand  climacteric. 

Paroxysmal  disturbances  of  the  nervous  system,  both  physiological 
and  pathological,  are  common  during  sleep.  Seminal  emissions,  the  vene- 
real orgasm,  and  urinary  incontinence  are  accidents  of  sleep.  Epileptic 
seizures — nocturnal  epilepsy — are  not  uncommon,  and  the  paroxysms  of 
asthma  and  migraine  frequently  come  on  in  sleep. 


FOCAL  INFECTION.  621 


Focal  Infection. 

Much  has  been  done  in  the  matter  of  focal  diseases  and  much  remains 
to  be  done,  and  the  absolute  necessity  of  the  harmonious  association  of 
clinicians  and  laboratory  workers  in  research  that  is  to  be  really  productive 
has  been  more  and  more  clearly  recognized ;  but  the  work  accomplished 
under  the  leadership  of  Billings  and  Rosenow  constitutes  an  epoch-making 
contribution  to  the  scientific  basis  of  the  art  of  medicine. 

It  is  important  that  certain  broad,  general  statements  should  be  made 
at  the  outset.  A  f ocns  of  infection  may  be  denned  as  a  circumscribed  surface 
or  tissue  invaded  by  pathogenic  microorganisms.  Such  foci  are  primary 
or  secondary.  Primary  foci  may  involve  a  mucous  or  cutaneous  surface. 
They  occur,  however,  commonly  in  the  complex  structures  of  the  face  and 
jaws,  the  upper  air  passages,  the  respiratory,  gastro-intestinal  and  genito- 
urinary tracts,  and  the  glandular  and  other  organs  severally  connected  with 
these.  Secondary  foci  arise  by  way  of  the  lymph- vessels  in  the  form  of 
infected  lymph-nodes,  or  by  way  of  the  blood-stream  in  distant  parts  or 
organs.  The  lesions  of  such  foci  are  frequently  embolic  and  often  widely 
disseminated. 

Local  inflammation  results  as  an  acute  process  with  or  without  abscess 
formation,  according  to  the  nature  of  the  infecting  organisms,  and  is  usually 
accompanied  with  more  or  less  severe  irregular  fever,  while  insidiously 
developing  visceral  and  cardiovascular  diseases  are  among  the  manifestations 
of  chronic  focal  infections  which  are  often  obscure  and  unsuspected.  The 
endocardium  and  pericardium  and  the  joints  and  periarticular  tissues  are 
particularly  liable  to  secondary  infection  derived  from  distant  limited  foci 
of  primary  infection. 

The  most  important  recent  contribution  to  the  subject  is  to  be  found 
in  the  work  of  Rosenow,  who  demonstrated  the  transmutability  of  the  mem- 
bers of  the  streptococcus-pneumococcus  group  in  form,  culture,  characteris- 
tics and  in  general  and  special  pathogenic  virulence  for  animals  and  the 
fact  that  the  property  of  transmutation  is  reversible  among  the  members 
of  this  group.  Scarcely  less  important  is  the  demonstration  of  the  fact  that 
the  bacteria  of  this  group  acquire  elective  tissue  affinity  in  foci  of  infection, 
in  culture  media  and  in  serial  animal  passage.  To  use  the  words  of  Rosenow, 
"The  underlying  conditions  which  tend  most  to  call  forth  changes  are,  first 
favorable  conditions  for  luxuriant  growth  and  then  unfavorable  conditions — 
under  stress  or  strain."  And  again,  "It  would  seem,  therefore,  that  focal 
infections  are  no  Longer  to  be  looked  upon  merely  as  a  place  of  entrance 
of  bacteria  but  as  a  place  where  conditions  are  favorable  for  them  to  acquire 
the  properties  which  give  them  a  wide  range  of  affinities  for  various 
structures. 

The  structures  of  the  mouth  and  upper  air  passages  are  peculiarly 
exposed  to  infection.  The  great  variety  of  pathogenic  microorganisms  pres- 
ent in  the  saliva  and  pharyngeal  mucus  constitute  a  universal  danger  of 
focal  infection.  The  most  trifling  Lesion  of  the  mucous  membrane  serves 
as  the  point  of  entrance  to  deeper  structures.  To  the  endameba  biiccalis, 
present  in  the  mouths  of  a  great  majority  of  persons,  according  to  several 


622  MEDICAL  DIAGNOSIS. 

observers  in  as  many  as  90  per  cent,  of  those  examined,  is  attributed  the 
most  common  initial  injury  to  the  edges  of  the  gums.  Similar  lesions 
result  from  the  maceration  of  food  particles  between  the  teeth  and  trauma- 
tism from  toothpicks  and  other  hard  substances.  Hence  arise  pyorrhoea 
dentalis  and  alveolar  abscess.  Enlarged  faucial  tonsils  and  hypertrophy 
of  the  adenoid  and  other  lymphnoid  tissues  of  the  nasopharynx  interfere 
with  respiration  and  drainage  and  favor  infection  of  those  structures  them- 
selves, the  middle  ear  and  the  accessory  sinuses.  In  this  manner  foci  of 
infection  are  established  in  a  large  proportion  of  children  and  many  adults. 
Focal  infections  in  the  gastro-intestinal  and  genito-urinary  tracts  are  less 
common. 

The  greater  number  of  individuals  thus  affected  do  not  suffer  from 
acute  or  chronic  diseases  due  to  focal  infection,  being  protected  by  the 
natural  defenses  of  the  body.  Such  persons  are  peculiarly  liable,  however, 
to  the  development  of  acute  and  chronic  organic  or  systemic  disease,  the 
predisposing  causes  being  profound  emotional  depression,  the  physical  ex- 
haustion resulting  from  exposure  to  cold,  privation,  insufficient  food,  pro- 
longed illness,  alcoholism,  general  anaesthesia  and  extreme  age. 

The  most  important  acute  disease  of  the  organs  of  respiration  is 
pneumonia,  or  to  speak  etiologically  in  view  of  the  work  of  Cole  and  his 
associates,  the  pneumo nias.  Sternberg  and  Pasteur,  by  a  curious  coincidence, 
discovered  in  1880  in  human  saliva  a  micrococcus  which  caused  fatal  septi- 
caemia in  rabbits  and  was  designated  the  coccus  of  sputum  septicaemia. 
Four  years  later  Fraenkel  demonstrated  the  fact  that  this  bacterium  is 
the  most  common  germ  in  lobar  pneumonia.  Its  causal  relationship  to  pneu- 
monia soon  became  generally  recognized  and  it  has  been  known  from  that 
time  as  the  pneumococcus  or  diplococcus  pneumoniae.  Notwithstanding  the 
fact  that  more  than  three  decades  have  elapsed  since  Fraenkel 's  discovery,  no 
satisfactory  comprehensive  explanation  of  the  occurrence  of  the  infection 
under  the  widely  varying  conditions  in  which  it  takes  place  has  yet  been 
formulated.     This  explanation  is  supplied  by  the  theory  of  focal-infection. 

For  this  reason  I  place  the  pneumonias  first  among  the  diseases  of  the 
respiratory  system  caused  by  focal  infection. 

Members  of  the  streptococcus-pneumococcus  group  have  been  shown 
to  be  present  in  the  mouths  of  a  large  number  of  individuals  apparently 
in  good  health,  the  proportion  according  to  various  observers  being  as  high 
as  80  or  90  per  cent.  They  vary  greatly  in  virulence.  In  many  persons 
they  are  apparently  harmless  denizens  of  the  oro-  and  nasopharyngeal 
spaces ;  in  others  they  are  always  virulent.  In  view  of  the  transmutability 
demonstrated  by  Rosenow,  changes  in  virulence  and  pathogenic  selective 
affinity  may  be  assumed  as  a  working  hypothesis.  The  virulence  increases 
under  conditions  favorable  to  luxuriant  growth.  What  these  conditions  may 
be  is  not  yet  fully  known.  They  are  doubtless  the  same  depressing  influences 
which  by  lowering  the  powers  of  the  individual  and  weakening  the  natural 
defenses  of  the  body  favor  systemic  infection  from  any  latent  focus.  Long- 
cope  and  Fox  found  the  saliva  of  the  same  person  more  virulent  in  cold 
weather. 

The  mucous  membrane  and  secretions  of  the  mouth  and  throat  harbor- 
ing virulent  pneumococci  constitute  a  focus  of  infection  in  the  same  sense 


FOCAL  INFECTION.  623 

as  the  genital  mucous  membrane  of  the  parturient  woman  infected  by  pyo- 
genic bacteria.  A  focus  of  infection  is  not  necessarily  a  small  circumscribed 
lesion  such  as  an  alveolar  abscess.  It  may  consist  of  a  great  mass  of  infil- 
trated tissue,  as,  for  example,  a  consolidated  lung. 

When  systemic  infection  with  virulent  pneumococci  takes  place  the 
primary  localization  is  in  the  lungs;  secondary  invasions  give  rise  to  endo- 
and  pericarditis,  peritonitis,  otitis,  sinusitis,  etc.,  and  these  affections  are 
described  as  complications.  The  pneumococcus  may  be  isolated  from  the 
blood.  Meta-pneumonic  empyema,  the  pneumococcic  type,  must  also  be  re- 
garded not  as  a  complication  but  as  an  infective  process,  secondary  to  the 
pneumonia  acting  in  turn  as  a  focal  infection.  Thus  an  autoinfection  occurs. 
This  is  in  the  great  majority  of  instances  the  mode  of  origin  of  pneumo- 
coccus pneumonia — the  sporadic  cases.  But  there  are  occasional  instances  in 
which  pneumonia  is  clearly  acquired.  The  nurse  after  some  days'  attend- 
ance upon  the  patient  has  a  chill,  and  forthwith  develops  pneumonia;  and 
there  are  house  epidemics,  three  or  four  cases,  and  less  frequently  more  or 
less  extended  load  outbreaks.  Under  these  circumstances  the  infection  is 
transmitted  in  the  usual  way.  Pneumonia  lends  itself  easily  to  transmission 
by  droplet  infection. 

The  conception  of  "focal  infection"  is  based  upon  four  fundamental 
facts : 

(a)  A  circumscribed  lesion  or  area  of  bacterial  infection.  Such  a 
lesion  is  usually  but  not  necessarily  small ;  a  pneumonic  lung,  a  gangrenous 
uterus  or  a  crushed  limb  may  constitute  the  primary  focus.  Nor  is  it 
essentially  a  mass  of  infected  tissue.  The  focal  lesion  in  sporadic  pneumonia 
and  in  diphtheria  involves  the  mucous  surface  of  the  upper  air  passages;  in 
erysipelas  the  inflamed  mucous  surface  or  skin  and  the  neighboring  or 
remote  infective  processes  constitute  so-called  complications. 

(b)  The  dissemination  from  the  focus  of  bacteria  by  way  of  the  circu- 
lating blood  or  lymph.  If  the  focal  bacteria  are  encapsulated  or  confined  to 
a  limited  space  under  conditions  which  prevent  their  access  to  the  body  at 
large,  infection  does  not  occur — nor  does  it  occur  as  long  as  they  remain 
non-virulent  or  quiescent.  These  facts  are  of  cardinal  importance  in  the 
consideration  of  operative  procedures. 

(c)  A  sysicmic  or  local  predisposition  to  the  action  of  pathogenic 
organisms  or  toxins.  There  may  be  a  natural  or  acquired  immunity  or  the 
genera]  defensive  forces  of  the  body  may  at  times  resist  infection.  Under 
these  circumstances  a  focus  of  virulenl  bacteria  may  becomes  comparatively 
innocuous  lesion. 

(d)  The  absorption  and  systemic  effects  of  bacterial  toxins.  Toxaemia 
having  its  source  in  an  infected  focus  is  an  important  factor  in  the  causation 
of  certain  forms  of  general  ill  health  and  morbid  conditions  of  various 
tissues  and  organs.  It  may  exert  its  deleterious  influence  directly  upon 
the  uervous  system,  the  heart  and  skeletal  muscles,  the  kidneys  and  other 
organs  or  indirectly  by  lowering  the  power  of  resistance  of  special  tissues  or 
viscera  and  thus  establishing  a  predisposition  to  bacterial  invasion. 

The  pyogenic  bacteria  are  the  most  common  factors  in  focal  infection, 
but  all  pathogenic  bacteria  may  he  present.  Mixed  infections  are  of  frequenl 
occurrence. 


624  MEDICAL  DIAGNOSIS. 

The  effects  of  focal  infection  may  be  manifested  in  any  tissue  or  struc- 
ture of  the  body.  The  serous  and  synovial  membranes  are  especially  liable 
to  infection.  Sepsis,  suppurative  lesions,  deep-seated  abscess  formations, 
endocarditis,  especially  the  ulcerative  form,  arthritis,  infected  thrombosis  are 
manifestations  of  focal  infection. 

The  diagnosis  involves  the  recognition  of  any  particular  morbid  con- 
dition as  due  to  focal  infection  and  the  location  of  the  focus.  The  former  is 
in  general  less  difficult  than  the  latter.  At  the  time  of  this  writing  many 
sins  are  being  committed  against  the  teeth  and  the  tonsils.  The  assertion 
that  the  removal  of  these  organs  as  a  diagnostic  procedure  is  justifiable  is 
not  wholly  true.  Such  operations  are  often  without  favorable  result ;  some- 
times followed  by  disaster  from  pulmonary  embolism  or  hemorrhage  or  the 
establishment  of  postoperative  infected  foci  in  the  locality  in  which  such  a 
lesion  did  not  previously  exist.  Recurrent  attacks  of  pneumonia,  acute 
rheumatic  fever,  erysipelas  and  other  paroxysmal  diseases,  such  as  gout, 
suggest  the  possibility  of  focal  infection  by  bacteria  of  long  periods  of 
attenuation  and  brief  outbreaks  of  virulence  ;  insidiously  developing  visceral 
disease,  in  the  absence  of  obvious  cause,  suggests  the  possibility  of  focal 
infection  with  resulting  toxsemia,  especially  in  view  of  the  fact  that  occasion- 
ally marked  improvement  in  health  has  followed  the  discovery  and  re- 
moval of  a  focus  of  infection.  In  all  such  cases  the  search  should  be 
systematically  made.  In  this  investigation  the  aid  of  the  skilled  specialist 
in  many  fields  of  medicine  may  have  to  be  invoked.  The  condition  of 
the  nasopharynx,  accessory  sinuses  and  ears,  of  the  jaws  and  teeth,  of  the 
joints  and  bones,  of  the  genito-urinary  and  pelvic  organs,  of  the  rectum  and 
prostate  must  be  carefully  investigated.  Rontgenograms  are  of  the  greatest 
importance  and  should  always  be  taken  by  an  expert  who  devotes  his  time 
to  that  special  work. 

Schick's  Test 

The  blood  of  a  large  proportion  of  normal  individuals  contains  diph- 
theria antitoxin  in  quantities  sufficient  to  constitute  immunity  against  the 
infection.  This  test  consists  in  the  injection  into  the  skin  of  an  amount  of 
diphtheria  toxin  equal  to  one-fiftieth  of  the  minimum  lethal  dose  for  a 
guinea-pig  weighing  250  grammes.  If  at  the  site  of  the  injection  there  is 
no  local  inflammatory  reaction  in  the  course  of  twenty-four  or  forty-eight 
hours  the  individual  very  rarely  acquires  the  disease.  If  such  a  reaction 
occurs  immunity  is  absent  and  there  is  liability  of  the  attack.  It  has  been 
estimated  that  in  the  former  case  the  blood  contains  one-thirtieth  unit  of 
diphtheria  antitoxin  or  more  per  cubic  centimetre  while  in  the  latter 
the  content  of  the  blood  is  less  than  this  amount.  The  investigations  of 
Schick,  Park,  Kolmer  and  others  have  shown  that  a  very  large  percentage 
of  the  newborn  and  adults  and  from  50  to  60  per  cent,  of  children  between 
the  first  and  fifteenth  years  possess  -relative  immunity  against  diphtheria. 
The  immunity  of  very  young  infants  is  probably,  like  that  which  they 
enjoy  against  other  acute  infections,  transmitted  from  the  mother,  and  the 
immunity  of  adult  life  may  have  been  acquired  by  a  mild  or  unrecognized 
attack  at  an  earlier  and  susceptible  age. 

The  outfit  devised  by  Zingher  of  the  Research  Laboratory  of  the  New 


ACIDOSIS.  625 

York  City  Department  of  Health,  and  consisting  of  a  capillary  tube  con- 
taining the  undiluted  diphtheria  toxin  and  a  bottle  holding  sterile  physio- 
logic saline  solution,  is  very  convenient  for  the  practitioner.1 

Schick's  test  should  be  employed  as  a  matter  of  routine  in  those  who 
have  been  recently  or  are  at  the  time  exposed  to  the  contagion  and  as  a 
protection  to  the  physicians,  nurses,  and  other  attendants  in  the  diphtheria 
wards. 

In  the  Philadelphia  Hospital  for  Contagious  Diseases  persons  yielding 
a  positive  reaction  under  these  circumstances  receive  a  series  of  three  injec- 
tions of  toxin-antitoxin  at  intervals  of  a  week.  These  injections  consist 
each  of  a  few  drops  of  a  standardized  90-per-cent.  overneutralized  solution  of 
toxin  and  antitoxin,  the  amount  of  toxin  remaining  the  same  while  the  anti- 
toxin is  increased  at  each  injection.  The  protection  thus  induced  is  of  much 
longer  duration  than  that  resulting  from  the  single  immunizing  doses  for- 
merly employed. 

Acidosis 

Notwithstanding  the  continuous  formation  of  acid  substances  in  the 
body  and  the  great  variations  in  the  ingestion  of  foods  containing  acid  and 
alkaline  substances,  the  reaction  of  the  blood  remains  nearly  constant  under 
normal  and  pathological  states.  This  reaction  is  slightly  alkaline.  It  is 
due  to  the  presence  of  sodium  salts  and  certain  feeble  acids,  principally 
carbonic  and  phosphoric.  When  the  acids  are  increased,  they  are  neu- 
tralized by  the  sodium  of  the  carbonates,  and  carbon  dioxide  is  set  free 
and  eliminated  by  the  lungs.  In  like  manner  the  base  of  the  phosphates 
neutralizes  acids  brought  to  them  and  the  acid-phosphate  remaining  is  elim- 
inated in  the  urine.  The  carbonates  and  phosphates  which  thus  stabilize 
the  reaction  of  the  blood  have  been  called  "buffer  substances"  (Henderson). 

The  term  acidosis  as  it  is  now  used  in  medicine  is  applied  to  a  condition 
characterized  by  a  general  abnormal  diminution  in  the  blood  of  these 
buffer  substances — namely,  bases  or  substances  which  give  rise  to  bases. 

The  designations  "acidosis"  and  "acid  intoxication"  are  unfortunate, 
since  no  marked  change  in  the  chemical  reaction  of  the  blood  takes  place 
and  an  actual  acidity  is  incompatible  with  life. 

Acidosis  is  always  a  secondary  condition.  The  acid-base  equilibrium 
is  maintained  by  four  principal  processes — the  excretion  of  CO..  by  the 
lungs;  tin'  function  of  the  kidney  in  separating  from  the  blood  which  is 
alkaline,  urine  which  is  acid;  the  capacity  of  the  blood  to  dispose  of  con- 
siderable  amounts  of  acid  or  alkali  without  appreciable  changes  in  H-ion  con- 
centration and  the  formation  of  ammonia  which  assists  in  the  neutralization 
of  acid  when  the  fixed  bases  are  no  longer  available.  When  any  one  of  these 
processes  is  deranged  acidosis  resulta 

Acidosis  may  be  recognized  by  changes  in  the  blood,  modifications  in  the 
respiration,  ami  alterations  in  the  urine.    » 

The  changes  in  the  blood  furnish  the  most  direct  evidences  of  acidosis 
hut  require  a  difficult  technic  uo1  available  for  ordinary  clinical  work. 

.Modifications  of  respiration  are  usually  present:  Air-hunger  hyper- 
pnaea — is  extremely  common  but  Dot  constant.   Its  occurrence  always  su^L'ests 

'Consult  Jr.  Ann  r.  Med.  Ann.,  Ixv,  pp.  :vju,  330. 
40 


626  MEDICAL  DIAGNOSIS. 

acidosis.  The  changes  in  the  blood  stimulate  the  respiratory  centre  with  the 
result  that  the  pulmonary  ventilation  is  increased  and  the  C02  tension  in 
the  alveoli  is  diminished.  The  alveolar  air  may  be  collected  by  the  Plesch- 
Levy  method  and  examined  by  the  Haldane  apparatus  for  gas  analysis.  The 
normal  tension  varies  between  39  and  45  mm.  A  reduction  of  C02  tension  in 
the  pulmonary  alveoli  may  also  occur  in  consequence  of  local  changes  in  the 
respiratory  centre. 

The  acetone  odor  of  the  breath  is  observed  in  cases  attended  with 
ketonuria. 

The  urine  in  acidosis  yields  information  of  importance  when  the  kidneys 
are  permeable.  The  ammonia  may  be  increased  or  decreased  according  to 
the  type  of  acidosis.  In  diabetes  and  cholera  the  ammonia  coefficient  usually 
rises ;  in  certain  types  of  nephritis  it  remains  low.  Acetone  and  the  acetone 
bodies  are  not  constant  in  acidosis,  nor  when  present  are  they  invariably 
the  indication  of  its  existence.  They  constitute  the  signs  of  a  disturbance 
of  carbohydrate  metabolism  and  ordinarily  increase  in  diabetic  acidosis  and 
at  times  in  any  type  of  acidosis,  especially  in  the  form  due  to  starvation. 
The  hydrogen  ion  concentration  of  the  urine  has  but  slight  clinical  signifi- 
cance. The  reactions  before  and  after  the  alkali  tolerance  test  are  misleading 
unless  the  excretory  capacity  of  the  kidneys  is  known  to  be  normal.  This 
test  is  therefore  available  only  in  selected  cases.  It  may  be  made  either 
by  the  mouth  or  intravenously.  Five  grammes  of  sodium  bicarbonate  are 
taken  by  the  mouth  in  a  moderate  quantity  of  water  every  two  or  three  hours, 
the  urine  being  voided  beforehand  in  each  instance.  Samples  of  urine  not 
clearly  acid  are  to  be  boiled  in  order  to  convert  bicarbonate  into  carbonate 
which  reacts  readily  to  litmus.  In  the  case  of  gastro-intestinal  disease  or 
when  large  doses  of  bicarbonate  are  indicated  intravenous  injection  may 
become  necessary.  Stringent  precautions  are  required  in  sterilization  to 
prevent  excessive  formation  of  the  carbonate.1 

Acidosis  plays  a  very  important  role  in  clinical  pathology.  In  varying 
degrees  of  intensity  it  occurs  in  starvation,  especially  after  sudden  depriva- 
tion of  food;  in  persons  on  a  protein-fat  diet,  without  carbohydrates,  par- 
ticularly when  carbohydrates  have  been  abruptly  withdrawn ;  in  diabetes 
mellitus,  the  nephritides,  cardiorenal  disease,  cholera,  pneumonia,  the  infec- 
tious fevers  and  grave  septic  states ;  in  surgical  anaesthesia  and  eclampsia. 
It  is  much  more  frequent  in  children  than  in  adults,  being  common  in  dis- 
eases characterized  by  severe  diarrhoea  and  vomiting  and  in  the  infections. 
The  more  severe  forms  of  acidosis  are  described  as  acid  intoxication,  and  are 
accompanied  by  the  presence  of  acetone  bodies  in  the  urine.  These  sub- 
stances, however,  may  occur  in  the  urine  in  the  absence  of  the  ordinary  signsi 
of  acidosis — diminution  in  the  tension  of  the  carbon  dioxide  content  of  the 
alveolar  air,  deepened  respiration  at  an  increased  rate,  increased  acidity  of 
the  urine  and  alkali  tolerance,  that  is,  failure  to  produce  an  alkaline  reaction 
of  the  urine  by  the  administration  of  five  grammes  of  sodium  bicarbonate. 

Although  five  grammes  is  the  quantity  of  sodium  bicarbonate  sufficient  to 
cause  the  urine  of  a  normal  individual  to  show  an  alkaline  reaction,  a  much 
greater  amount  may  fail  to  do  so  in  persons  wholly  free  from  clinical  symp- 
toms of  acidosis.    With  a  tolerance  of  seventy-five  grammes  or  more  dyspnoea 

1  Consult  Sellard's  "  The  Principles  of  Acidosis  and  Clinical  Methods  for  Its  Study,"  1917. 


DEHYDRATION.  627 

appears ;  with  one  hundred  and  fifty  grammes,  air  hunger.  It  is  therefore 
important  that  the  carbon  dioxide  test  of  the  alveolar  air  or  the  alkali  toler- 
ance test  should  be  employed  when  severe  symptoms  occur  under  conditions 
which  favor  the  development  of  acidosis  even  in  the  absence  of  the  signs 
of  that  syndrome,  in  order  that  in  so  far  as  possible  its  special  causes  may 
be  removed.  It  is  fortunate  that  the  alkali  tolerance  test  is  at  the  same  time 
a  therapeutic  measure.  In  the  severe  acidosis  of  diabetes  Joslin  recommends 
the  free  administration  of  hot  liquids,  such  as  water,  thin  broths,  tea  to  the 
extent  of  1000  c.c.  in  the  course  of  every  six  hours,  cleansing  enemata,  and 
the  withdrawal  of  fats  from  the  diet.  Small  amounts  of  carbohydrates  are 
to  be  given  and  alkali  omitted  or  withdrawn. 

Dehydration 

Litchfield  (1918) J  has  recently  called  attention  to  the  important  part 
played  in  the  symptom-complex  of  many  serious  diseases  by  the  deprivation 
of  water.  His  clinical  studies  are  based  upon  the  laboratory  researches 
of  Erlanger  and  Woodyatt  (1917)2  and  Wilder  and  Sansum  (1917)3.  After 
a  brief  review  of  the  well-known  facts  concerning  water  from  the  viewpoints 
of  anatomy  and  physiology,  he  proceeds  to  enumerate  the  symptoms  result- 
ing  from  the  gradual  or  rapid  deprivation  of  water  in  disease.  The  clinical 
picture  is  a  familiar  one,  being  made  up  of  phenomena  due  to  the  specific 
effects  of  the  primary  infection,  the  toxamiia  of  retained  waste  products  and 
nitrogen  starvation.  It  is,  however,  obvious  that  the  deficiency  of  water  is 
of  fundamental  importance.  The  following  symptoms  are  characteristic : 
Rapid  respiration,  a  feeble,  thready  pulse  of  high  frequency,  a  systolic 
blood-pressure  of  70  or  60.  The  tongue  is  parched  and  protruded  with 
difficulty;  the  surface  is  dry  and  cool  and  the  skin  shrivelled,  especially 
upon  the  extremities.  The  features  are  drawn  and  pinched,  the  eyeballs 
sunken,  tin-  intra-ocular  tension  lowered.  There  is  diminished  secretion  of 
urine,  sometimes  complete  suppression.  Constipation  is  common,  though 
diarrhoea  frequently  occurs.  The  mental  condition  varies  from  more  or  less 
complete  apathy,  to  restlessness  and  irritability  passing  into  low,  muttering 
delirium  and  coma. 

Tin-  water  equilibrium  may  be  deranged  by  diminished  intake  or  in- 
creased output.  In  extreme  cases  both  may  be  operative.  The  intake  may 
be  reduced  in  consequence  of  nausea,  immediate  rejection  by  vomiting  or 
by  morbid  conditions  of  the  mouth,  throat  or  (esophagus  which  prevent  swal- 
lowing,  or  of  the  gastro-intestinal  tract  which  prevent  absorption.  Finally 
apathy,  delirium  or  coma  may  render  it  impossible  for  the  time  being  to 
administer  sufficient  fluid.  As  the  taking  of  food  is  practically  impossible,  a 
starvation  acidosis  of  acute  and  dangerous  type  is  likely  to  occur. 

A  dangerous  Loss  of  fluid  may  fie  caused  by  persistent  vomiting,  profuse 
diarrhoea,  excessive  perspiration  or  hemorrhage.  Rapidly  forming  inflam- 
matory exudates  into  tic  serous  cavities  constitute  an  important  cause  of 
dehydration,  in  particular  when  such  effusions  are  repeatedly  aspirated. 

The  above-described  water  starvation  is  seen  in  many  grave  infectious 

'  Glucose  Therapy,  The  President's  Addre  ■  Ti  on  Praet.,  A.M  \.,  i'iis. 

'Intravenous  Glucose  Injections  in  Shock,  Jr.  A.  M  A.,  Oct.  l'7,  mm  7,  p.  l  HO. 
'A  Glucose  Tolerance  in  Health  and  Disease,  Arch.  Int.  Med.,  Feb.,  1917,  p.  311, 


628  MEDICAL  DIAGNOSIS. 

diseases  and  is  frequently  the  forerunner  of  death.  Among  the  conditions 
in  which  it  is  especially  liable  to  occur  are  fevers  of  the  typhoid  group, 
sepsis,  especially  postoperative  and  puerperal  sepsis,  peritonitis,  the  menin- 
gitides  and  cerebral  abscess,  the  pneumonias,  empyema,  pleural  effusion  and 
Shiga  dysentery.  The  most  striking  forms  of  acute  dehydration  are  seen 
in  large  hemorrhages  and  in  cholera  Asiatica  and  severe  cases  of  cholera 
nostras. 

The  condition  of  dehydration  closely  resembles  surgical  shock  and  has 
been  treated  among  other  measures  with  some  degree  of  success  by  the 
attempt  to  anticipate  its  occurrence  or  to  restore  the  lost  fluid  by  injections  of 
physiological  salt  solution — enteroclysis,  hypodermoclysis  and  the  Murphy 
drip.  It  is  a  result  of  the  experimental  use  of  glucose  in  the  treatment 
of  artificially  produced  shock  in  animals  that  its  employment  in  the  treat- 
ment of  dehydration  in  human  beings  has  attracted  attention.  "On  theo- 
retical and  experimental  grounds  supported  by  some  clinical  evidence,  it 
would  appear  that  intravenous  injections  of  glucose  at  appropriate  rates 
are  of  distinct  benefit  in  certain  phases  of  shock  "  (Erlanger  and  Wood- 
yatt)1.  The  prognosis  in  a  condition  frequently  terminal  has  been  so  often 
favorably  influenced  by  the  intravenous  injection  of  suitable  amounts 
of  hypertonic  glucose  solution  that  it  is  referred  to  in  this  connection. 
Among  the  effects  are  improvement  in  the  general  appearance  of  the 
patient,  the  clearing  of  the  facies,  slowing  of  the  respiration  and  pulse,  a 
rise  in  the  systolic  blood-pressure,  a  moistening  of  the  tongue  and  mouth. 
The  kidneys  and  bowels  resume  their  functions  and  the  mind  clears.  The 
patient  asks  for  water  and  food  and  presently  may  fall  asleep. 

The  rate  of  administration  is  0.8  gramme  per  kilogram  of  body  weight 
per  hour  of  a  25  per  cent,  solution.  Rigorous  sterilization  of  the  water, 
glucose  and  apparatus  is  to  be  observed.  For  details  of  the  technic  con- 
sult the  articles  referred  to  in  the  footnotes. 

Functional  Tests. 

The  exact  determination  of  the  efficiency  of  the  so-called  vital  organs, 
the  liver,  kidneys,  pancreas,  heart,  and  ductless  glands  would  be  of  the 
highest  importance  in  the  diagnosis  of  the  early  periods  of  disease  affect- 
ing these  organs,  the  recognition  of  atypical  cases  and  prognosis.  Much 
of  the  work  thus  far  accomplished  in  this  field  of  clinical  pathology  is 
inconclusive  and  much  is  unsuited  to  ordinary  bedside  purposes.  The  fol- 
lowing tests  are  of  practical  importance.2 

TESTS  OF  LIVER  FUNCTION 

The  Glycogenic  Function. 
The  Carbohydrate  or  Sugar  Tests. 

Under  certain  conditions  glucose  is  not  retained  in  the  cells,  but  passes 
directly  into  the  blood,  causing  hyperglycemia.  Under  these  circumstances 
it  is  excreted  in  the  urine  more  or  less  continuously  and  in  varying  amounts. 

i  Loc.  cit. 

2  Consult  also  Barton.  Manual  of  Vital  Functions,  Testing  Methods  and  Their  Interpretations. 
Boston.    2nd  Ed.    Badger,  1917. 


FUNCTIONAL  TESTS.  629 

1.  The  Cane  Sugar  Test. — One  hundred  and  fifty  or  200  grammes  of 
cane  sugar  syrup  are  taken  fasting.  The  urine  is  collected  at  intervals  and 
examined  by  suitable  tests.  See  page  301  et  seq.  The  glucose  reaction 
renders  the  test  positive.  This  test  is  invalidated  by  the  fact  that  there 
are  no  methods  by  which  the  completeness  of  the  conversion  of  cane  sugar 
into  glucose  by  the  action  of  the  intestinal  juices  can  be  known. 

2.  The  Glucose  Test. — One  hundred  and  fifty  grammes  of  dextrin-free 
glucose  in  300  c.c.  of  water  are  administered  to  the  fasting  patient  in  the 
morning.  The  urine  collected  at  intervals  of  an  hour  in  separate  vessels  is 
tested  for  glucose.  A  positive  reaction  is  not  conclusive  and  the  test 
should  be  repeated  at  intervals  of  some  days,  due  regard  being  paid  to  the 
permeability  of  the  kidneys  and  the  possibility  of  spontaneous  glycosuria 
after  meals. 

3.  The  Levulose  Test. —  (Honey  may  be  used  as  a  substitute). — One 
hundred  grams  of  levulose  is  taken  fasting  and  the  urine,  voided  at  inter- 
vals of  four  hours,  is  examined  by  the  fermentation  test  or  the  polariscope. 
See  page  304.  This  quantity  should  not  cause  levulosuria  in  a  normal 
person.  Much  was  expected  from  this  test  because  levulose  is  not  changed 
during  digestion  as  it  is  absorbed  as  such.  It  has,  however,  shown  in 
practice  no  advantages  over  the  other  sugar  tests  for  functional  efficiency 
of  the  liver. 

4.  The  Galactose  Test. — Forty  grammas  of  galactose  dissolved  in  400 
c.c.  of  water  or  tea  taken  on  an  empty  stomach  in  the  morning.  The  urine  is 
collected  at  intervals  and  tested  for  sugar.  See  page  303.  In  catarrhal 
jaundice  the  reaction  for  sugar  is  fairly  constant. 

The  sugar  tests  yield  positive  reactions  in  cirrhosis,  icterus  gravis,  and 
cholelithiasis  and  in  greater  frequency  in  catarrhal  than  in  obstructive 
jaundice ;  but  they  are  complicated  by  unknown  factors  among  which  in- 
testinal absorption  and  renal  permeability  are  the  most  obvious. 

The  Ureagenetic  Function. 

Most  of  the  tests  for  derangements  of  this  function  of  the  liver  are  so 
complicated  that  they  cannot  be  carried  out  except  by  an  expert  chemist, 
and  there  are  many  undeterminable  physiological  factors  which  serve  to 
modify  the  results.  For  these  reasons  this  series  of  tests  are  not  available  for 
ordinary  clinical  work. 

The  Antitoxic  Function. 

The  tests  for  the  integrity  of  this  function  of  the  liver  depend  upon 
the  fact  that  poison-  reaching  the  organism  by  way  of  the  portal  circula- 
tion are  arrested  and  destroyed  by  the  liver  cells. 

1.  The  Methylene  Blue  Test. — Inject  5  c.c.  of  a  5  per  cent,  solution  cf 
methylene  blue  subeutaneously.  Collect  and  examine  the  urine  at  firsl  in 
half  an  hour,  subsequently  at  hourly  intervals.  Normally  it  is  colored  at 
the  first  examination,  the  coloration  attaining  its  maximum  intensity  in 
three  or  four  hours  and  disappearing  in  aboul  forty-eight  hours.  If  the 
elimination  is  not  continuous  but  intermittent,  the  test  is  positive  as  indi- 
cating insufficiency  of  the  hepatic  cells. 


630  MEDICAL  DIAGNOSIS. 

2.  Roche's  Modification. — The  methylene  blue  .002  gm.  is  given  by 
the  mouth  in  capsule  in  the  morning  on  an  empty  stomach.  The  urine 
is  collected  every  four  hours  in  separate  vessels.  If  the  second  voiding  is 
colored,  the  inability  of  the  liver  cells  to  arrest  the  pigment  is  established. 
The  urine  of  the  later  voidings  is  colored  green.  The  permeability  of  the 
kidneys  must  be  previously  ascertained.    See  page  309. 

3.  Indicanuria  as  a  Test  of  the  Fixation  Function  of  the  Cells. — It 
has  been  assumed  that  the  normal  liver  is  physiologically  capable  of  de- 
stroying the  indican  which  is  formed  in  the  intestine  as  the  result  of  the 
putrefaction  of  albuminoids.  It  would  follow  that  the  spontaneous  pres- 
ence of  indican  in  the  urine  is  evidence  of  impairment  of  the  function  of 
the  hepatic  cells. 

Provocative  Indicanuria. — The  patient  is  restricted  to  an  exclusive 
milk  diet  for  a  few  days.  One-thousandth  gm.  of  indol  is  administered 
on  an  empty  stomach.  The  urine  is  collected  every  four  hours  and  ex- 
amined for  indican.     A  positive  result  indicates  impaired  hepatic  function. 

Obermayer's  Test. — See  page  293. 

The  Sanguinopoietic  Function. 
Estimaticn  of   Blood  Coagulation   Time. 

1.  Wright's  Method. — See  page  256. 

2.  The  Fibrinogen  Test. — A  rough  estimate  of  the  fibrinogen  content 
of  the  blood  may  be  made  by  coagulating  a,  little  plasma  with  calcium  and 
testing  the  firmness  of  the  clot  with  a  glass  rod. 

3.  Whipple  Horwitz  Method. — Fibrinogen  is  precipitated  by  subject- 
ing 20  c.c.  of  oxalated  plasma  to  a  temperature  of  59°  C.  for  twenty 
minutes.  The  precipitate  is  separated  by  centrif ligation,  washed  with 
sterilized  water,  alcohol  and  ether,  dried  at  120°  C.  and  weighed.  The 
normal  fibrinogen  content  of  the  blood  plasma  is  .30  to  .40  gm.  to  100  c.c. 
The  proportion  is  diminished  in  general  lesions  involving  the  parenchyma 
of  the  liver.     In  cirrhosis  it  is  frequently  low. 

4.  The  Fibrinolysis  Time. — The  clot  of  normal  blood  remains  undi- 
gested for  some  days  or  weeks.  It  has  been  suggested  that  the  dissolution 
of  the  clot  is  caused  by  the  action  of  an  enzyme.  In  cases  of  cirrhosis  the 
blood  digests  the  clot  in  a  few  hours  at  body  temperature.  The  activity  of 
the  enzyme  in  question  is  destroyed  by  heat  and  inhibited  by  normal  serum. 

The  Goodpasture  Test. — Blood  is  obtained  from  a.  vein  in  the  arm 
and  the  coagulation  time  is  estimated.  A  portion  of  the  blood  is  drawn 
into  1  per  cent,  solution  of  sodium  oxalate  to  prevent  clotting.  This  speci- 
men is  centrifugated  and  the  fibrinogen  content  estimated.  Portions  of 
the  clot  and  specimens  of  oxalated  serum  are  placed  in  the  thermostat  at 
37°  C.  They  are  examined  at  intervals  of  an  hour.  If  the  test  is  positive 
the  clot  liquefies  and  is  wholly  dissolved  in  three  and  one-half  to  five  hours ; 
if  negative  there  is  no  dissolution  of  the  clot  for  several  days. 

The  Biliary  or  Exocrinous  Function. 
1.  Tests  for  Biliary  Pigments. — See  page  294. 


FUNCTIONAL  TESTS.  631 

TESTS  OF  KIDNEY  FUNCTION. 

The  Water  Tests. 

1.  Provocative  Polyuria  Test. — The  morning  urine  is  measured  and 
its  specific  gravity  taken.  Its  total  sodium  chloride  and  urea  are  to  be 
estimated.  The  patient  then  drinks  500  c.c.  of  ordinary  or  mineral  water. 
The  urine  is  collected  every  half  hour  by  voiding  or  catheter,  if  the  gen- 
eral renal  function  is  to  be  studied;  or  by  ureteral  catheterization  if  the 
function  of  each  kidney  is  to  be  compared.  The  maximum  polyuria  is 
reached  under  normal  conditions  at  the  end  of  the  first  half  hour,  and  the 
total  solids  diminish.  If  the  renal  function  is  impaired  the  polyuria  is 
delayed  or  does  not  occur. 

2.  The  Strauss=Grunwald  Test. — The  patient  takes  no  drink  or  food 
after  7  p.m.  At  6.30  a.m.  the  night  urine  is  collected  and  he  drinks  500  c.c. 
of  water.  The  urine  voided  at  7,  8,  9,  10  and  11  a.m.  is  collected  and  the 
respective  quantity  and  specific  gravity  of  each  portion  determined.  Dur- 
ing this  whole  period  the  patient  rests  quiet  in  bed  or  upon  a  couch. 
Normally  the  amount  voided  equals  that  taken,  at  the  beginning,  so  that  by 
10  o'clock  he  will  have  passed  a  pint.  About  8  a.m.  the  specific  gravity  is 
at  its  lowest.  Variations  in  the  amount,  time  and  specific  gravity  point  to 
derangement  of  the  renal  function. 

Scdium  Chloride  Tests. 

1.  Mohr's  Method. — See  page  292. 

2.  A  rough  estimate  of  the  sodium  chloride  content  of  the  urine 
may  be  made  by  adding  to  a  test  tube  of  clear  urine  free  from  albumin  ten 
drops  of  pure  UNO.,  and  one  drop  of  1  to  8  solution  of  Aq.NO,,.  If 
chlorides  are  normal  or  increased  a  precipitate  forms  as  a  compact  ball 
which  slowly  sinks;  if  diminished,  the  globular  mass  of  precipitate  is  less 
compact :  if  greatly  diminished,  it  forms  a  cloud  without  solid  Makes. 

Estimation  of  Urinary  Nitrogen. 

The  kidney  does  not  play  any  part  in  nitrogen  metabolism.  Its  func- 
tion  is  to  excrete  nitrogenous  waste  products  brought  to  it  in  the  blood 
current.  Urinary  nitrogen  as  an  index  of  renal  function  is  represented  by 
the  amount  of  urea  eliminated  under  normal  conditions,  the  patient  being 
in  ;i  fixed  diet  and  pursuing  the  same  course  of  life,  with  an  estimate  of 
the  power  of  the  kidneys  to  eliminate  more  urea,  when  the  proteid  intake 
a  increased  or  urea  itself  is  ingested.  The  ordinary  routine  estimation 
of  the  amount  of  urea  in  the  urine  without  the  precaution  of  a  fixed 
regimen  is  insignificant.  If  under  proper  precautionary  measures  the 
constant  approximately  normal  output  of  urea,  about  30  to  34  grammes 
in  twenty-four  hours,  is  maintained,  the  renal  function  of  the  kidneys  may 
1m-  assumed  to  be  equal  to  the  physiological  requirement  of  the  individual. 
This  is  especially  true  if,  the  proteid  intake  being  increased,  the  urea  out- 
put shows  a  prompt  corresponding  rise. 

1.  Marshall's  Method  of  Urea  Estimation.  This  method  depends 
upon  the  conversion  of  urea  into  ammonium  carbonate  by  the  action  of  an 


632  MEDICAL  DIAGNOSIS. 

enzyme  prepared  from  soy  bean.  This  enzyme,  in  a  form  suitable  for  im- 
mediate use  and  called  urease,  is  prepared  in  the  Hynson,  Westcott  and 
Dunning  Laboratory.  To  estimate  the  amount  of  urea  in  irine,  determine 
with  decinormal  hydrochloric  acid  and  methyl  orange  the  degree  of  natural 
alkalinity  of  a  portion  of  the  specimen  treated  with  the  enzyme  and  com- 
pare it  as  to  alkalinity  with  an  equal  quantity  of  the  same  specimen  not 
so  treated.  The  difference  represents  the  ammonium  carbonate  formed  by 
the  breaking  up  of  the  urea  present.  The  amount  of  urea  is  ascertained 
by  calculating  its  equivalent  in  ammonium  carbonate.     See  also  page  290. 

2.  Ambard's  Urea=Coefficient. — This  investigator,  as  the  result  of  his 
comparative  simultaneous  studies  of  the  urea-content  of  the  blood  and  the 
urine  in  normal  subjects,  concluded  that  (1)  when  the  concentration  of 
urea  in  the  urine  is  constant,  the  excretion  varies  directly  as  the  square  of 
the  concentration  of  urea  in  the  blood,  and  (2)  when  the  concentration  of 
urea  in  the  blood  remains  constant,  the  excretion  varies  inversely  as  the 
square  root  of  the  concentration  in  the  urine,  and  (3)  that  other  factors 
being  the  same,  the  excretion  varies  directly  with  the  weight  of  the  indi- 
vidual. These  conclusions  are  known  as  Ambard's  laws,  the  mathematical 
formula  by  which  they  are  expressed  as  Ambard's  coefficient,  and  the  con- 
stant is  indicated  by  the  symbol  "K, "  the  value  of  which  is  in  normal 
human  beings  0.08,  but  in  cases  of  renal  disease  attended  with  an  increase 
in  the  concentration  of  blood  urea  and  a  decrease  of  the  elimination  of 
urea  in  the  urine  the  value  of  "K"  is  greatly  increased.  This  method  of 
renal  function  testing  is  not  available  for  the  practitioner.1 

3.  Provocative  Urea  Test. — Thirty  grammes  of  urea  dissolved  in  a  small 
tumblerful  of  water  are  given  with  a  light  breakfast  consisting  of  gruel  or 
some  cereal.  Additional  water  is  taken  afterwards  to  induce  diuresis. 
The  urine  is  collected  two  hours  before  the  breakfast  as  a  standard  for 
comparison  and  every  two  hours  afterwards  for  twenty-four  hours,  and 
the  urea  content  of  the  different  specimens  determined  at  the  end  of  the 
period.  Normally  there  is  a  marked  rise  in  urea  excretion  on  the  second 
two-hour  period.  The  absence  or  delay  of  such  a  rise  indicates  deficiency 
of  kidney  function.  This  test  is  invalidated  by  gastric  stasis  or  delay 
absorption  from  any  cause; 

Dietary   Test   of  Kidney  Function.     Twenty-four  Hour   Test   Meals   for 

Nephritic  Function.2 

This  functional  test,  originally  suggested  by  Hedinger  and  Schlayer 
(1914)  and  fully  worked  out  by  Mosenthal  (1915),  has  proved  of  great 
importance  in  the  clinical  study  of  renal  function  and  come  rapidly  into 
general  use.  It  has  yielded  practical  results  in  the  diagnosis  of  the 
forms  of  kidney  disease,  various  cardiopathies  and  other  conditions  at- 
tended with  derangements  of  urinary  output  and  dropsical  states.     The 

1"If  we  decline  to  consider  the  kidney  a  fixed  and  unchanging  valve  in  the  bottom  of  a  cylinder  of 
blood,  and  remember  that  it  is  of  the  same  fundamental  substances  and  subject  to  the  same  laws  that  apply 
to  blood,  then  we  cannot  be  so  exacting  in  our  demand  for  mathematical  relationship  between  the  blood 
urea  and  urine  urea.  Since  this  organ  of  excretion  is  itself  so  largely  composed  of  blood,  it  seems  obvious 
that  its  function  cannot  be  expressed  bv  a  constant  but  will  depend  on  the  physico-chemical  changes  that 
may  occur  in  the  blood.  There  may,  therefore,  be  shifts  in  the  constituents  of  the  blood  that  will  not  be 
mirrored  bv  the  urine."     Atchlev,  Arch.  Int.  Med.,  vol.  22,  No.  3,  191-8. 

2  Arch.  Int.  Med.,  1915,  xvi,  p.  733  et  seq.,  and  Barton,  p.  97  et  seg. 


FUNCTIONAL  TESTS. 


633 


urinary  water  and  specific  gravity  are  accurately  determined  at  intervals 
of  two  hours.  The  salt  and  nitrogen  are  estimated  for  the  day  and  night 
specimens. 

The  following  schedule  contains  the  directions  for  the  test  meals : 

DIET 

TEST   MEALS   FOR   NEPHRITIC    FUNCTION 

For    Date 

All  food  is  to  be  salt-free  food  from  the  kitchen. 

Salt  for  each  meal  is  to  be  furnished  in  weighed  amounts.  One  capsule  of  salt, 
containing  2.3  gm.  sodium  chloride,  is  furnished  with  each  meal.  The  salt  which 
is  not  consumed  is  returned  to  the  laboratory,  where  it  is  weighed,  and  the  actual 
amount  of  salt  taken  calculated. 

All  food  or  fluid  not  taken  must  be  weighed  or  measured  after  meals,  and  charted 
in  the  spaces  below. 

Allow  no  food  or  fluid  of  any  kind  except  at  meal  times. 

Xote  any  mishaps  or  irregularities  that  occur  in  giving  the  diet  or  collecting  the 
specimens. 

Breakfast,  8  a.  >r. 
Boiled  oatmeal,   100  gm.  Coffee,   160  c.c. 

Sugar,  V-2.  teaspoonful.  Sugar,   1  teaspoonful. 

Milk,  30  c.c.  Milk,  40  c.c. 

Two  slices  bread    i  30  gm.  each).  Milk,  200  c.c. 

Butter,  20  gm.  Water,  200  c.c. 


Dinner,    12   Noon 


Meat  soup,  180  c.c. 
Beefsteak,  100  gm. 
Potato    (baked,   mashed  or  boiled) 

gm. 
Green  vegetables  as  desired. 
Two  slices  bread   (30  gm.  each). 


Two  eggs,  cooked  any  style. 
Two  Blicea  bread    (30  gm.  each) 
Butter,  20  gm. 
Tea,  180  c.c. 


Butter,  20  gm. 
Tea,  180  c.c. 
,    130       Sugar,  1  teaspoonful. 
Milk.  20  c.c. 
Water,  250  c.c. 
Pudding   (tapioca  or  rice).  110  gm. 

Supper,  5  p.  m. 

Sugar,   1  teaspoonful. 

Milk,  20  c.c. 

Fruit    (  stewed  or  fresh  ) ,  1   portion. 

Water,  300  c.c. 


8  A.  M. — Xo  food  or  fluid  is  to  be  given  during  the  night  or  until  8  o'clock  the  next 
morning   (after  voiding),  when  the  regular  diet  is  resumed. 

Patient  is  to  empty  the  bladder  at  8  v.  m.  and  at  the  end  of  each  period,  as  indi- 
cated below.  The  specimens  arc  to  be  collected  for  the  following  periods  in  properly 
labelled  bottles: 

8      \.  M.     HI     A.M..     10     A.  M.-12     N..     12     N.-2     P.M.,     2     P.  M.-4     P.M..     4     P.  M.-fl     P.M., 

6    P.  M.    S    P.  M..    S    p.    \I.    S    A.    \l. 

The  diel  subjects  the  kidneys  to  a  certain  amounl  of  temporary  stress 
since  if  contains  substances  which  ad  as  diuretics.  It  contains  aboul  1;>.4 
gm.  nitrogen,  8.5  gm.  Bait,  and  1760  c.c.  wafer,  with  purin  material  in  the 
soup,  meat,  tea  and  coffee.  It  is  essential  to  the  tesi  that  the  urine  be 
collected  exactly  al  the  stated  intervals,  thai  no  food  or  fluid  of  any  kind 
be  taken  between  meals  or  during  the  night  and  thai  the  complete  twelve- 


634  MEDICAL  DIAGNOSIS. 

hour  night  specimen  be  fully  voided  before  breakfast.  These  precautions 
are  necessary  in  view  of  the  promptness  with  which  the  kidneys  respond 
to  the  ingestion  of  fluid. 

The  urine  of  healthy  subjects  undergoing  this  dietary  test  shows: 

1.  Variations  in  the  specific  gravity  of  the  two-hour  specimens  reach- 
ing nine  points  or  more.  The  variations  are  less  when  the  amount  of  fluid 
is  reduced  or  there  is  diminished  urinary  secretion. 

2.  An  approximate  balance  between  the  output  and  intake  of  salt, 
nitrogen  and  fluids. 

3.  A  night  urine  of  high  specific  gravity,  1016  or  more;  moderate 
amount,  not  exceeding  400  c.e.  and  uninfluenced  by  the  amount  of  fluid 
ingested  or  urine  voided  during  the  day. 

It  is  a  function  of  the  kidney  in  health  to  concentrate  or  dilute  the 
urine  readily  and  thus  maintain  the  normal  concentration  of  the  fluids 
of  the  body.  Failure  of  this  function  shows  itself  in  fixation  of  the  specific 
gravity.  This  sign  is  therefore  an  indication  of  disease  which  may  pri- 
marily reveal  itself  as  nephritis  or  as  extra-renal  and  secondarily  impair- 
ing- the  function  of  the  kidney,  as  cystitis,  pyelitis,  hydronephrosis,  renal 
congestion  of  cardiac  origin,  diabetes  or  anamria. 

An  increase  of  the  amount  of  night  urine  beyond  400  c.c.  is  an  early 
symptom  of  nephritis  and  may  precede  by  some  time  distinct  albuminuria 
and  the  presence  of  casts. 

The  Response  to  the  Dietary  Test  in  Disease. — Chronic  Interstitial 
Nephritis. 

1.  Fixed  and  low  specific  gravity. 

2.  Diminished  output  of  salt  and  nitrogen. 

3.  Polyuria. 

4.  Night  urine  differing  from  the  normal  is  increased  in  amount;  low 
specific  gravity  and  low  nitrogen  concentration. 

These  responses  vary  with  the  grade  of  the  pathological  changes  in  the 
kidney  and  become  very  marked  in  advanced  cases.  Similar  responses  to 
the  dietary  test  are  encountered  in  disease  of  the  urinary  passages,  as  pros- 
tate enlargement,  cystitis,  ureteritis  and  pyelitis;  ana?mias  of  high  grade 
and  in  certain  diseases  of  the  kidney  other  than  the  nephritis,  as  pyelo- 
nephritis and  polycystic  kidneys. 

Renal  Congestion  from  Myocardial  Insufficiency. 

1.  Specific  gravity  fixed,  usually  about  1020. 

2.  Low  output  for  salt. 

3.  A  sufficient  nitrogen  output. 

4.  Persistent  diminished  urinary  water. 

5.  Normal  night  urine. 

During  the  elimination  of  the  oedema : 

1.  Low  specific  gravity  tending  to  fixation. 

2.  Nitrogen  normal. 

3.  Salt  output  in  excess  of  intake. 

4.  Water  elimination  greater  than  intake. 


FUNCTIONAL  TESTS.  635 

After  the  oedema  has  disappeared  the  response  to  the  dietary  test  still 
indicates  impaired  renal  function  as  shown  by  condition  resembling  those 
in  interstitial  nephritis. 

1.  Specific  gravity  low  and  tending  to  fixation. 

2.  Normal  nitrogen  and  water. 

3.  Salt  output  somewhat  diminished. 

4.  Night  urine  variable  in  amount.     It  may  or  may  not  be  increased. 

5.  Nitrogen  concentration  low. 

Chronic  Parenchymatous  Nephritis. — During  the  period  of  oedema  the  test 
response  is : 

1.  High  specific  gravity. 

2.  Salt  and  water  retention. 

3.  Nocturnal  polyuria. 

4.  Good  nitrogen  elimination. 

With  the  disappearance  of  oedema  the  response  is  similar  to  that  in 
eases  of  myocardial  insufficiency  under  the  same  conditions. 

The  Blood  in  the  Estimation  of  Renal  Function. 

Impaired  renal  function  results  in  the  accumulation  of  the  nitrogenous 
products  of  metabolism  in  the  blood.  It  follows  that  marked  accumulation 
of  incoagulable  nitrogen  or  of  urea  is  evidence  of  renal  insufficiency.  In 
cases  of  nephritis  such  accumulation  is  an  ominous  prognostic  sign. 

1.  The  determination  of  the  urea  in  the  blood  may  be  most  rapidly 
and  accurately  made  by  the  method  of  Marshall,  while  the  technic  of 
estimating  total  incoagulable  or  residual  nitrogen  in  the  blood  serum  yields 
satisfactory  results  by  Morris'  modification  of  the  IInhlwe<r-Meyer  plan  or 
that  of  Folin  and  Denis.  These  tests  require  a  well-appointed  laboratory 
and  are  impracticable  for  the  general  practitioner. 

2.  The  blood  coagulation  time  as  a  test  for  renal  function  requires 
20  c.c.  of  blood  and  is  not  available  for  general  use. 

3.  Cryoscopy  has  not  come  into  general  use.    See  page  308. 

The  Elimination  of    Foreign  Substances  by  the  Kidneys  as  a  Test  of  Function. 

1.  Potassium  iodide,  phloridzin  and  hippuric  acid  have  been  used  for 
tiiis  purpose,  but  their  employment  in  the  clinic  has  been  abandoned. 

2.  The  Lactose  Test. —  It  has  been  experimentally  established  that  this 
substance  may  be  regarded  as  an  index  of  the  vascular  and  glomerular 
function  of  the  kidney.  The  technic  is  as  follows:  Two  and  five-tenths 
grams  of  pure  lactose  are  dissolved  in  25  c.c.  of  freshly  distilled  water  and 
pasteurized  for  four  hours  upon  four  successive  days  at  a  temperature  of 
80°  C.  A  fresh  solution  must  be  prepared  for  each  injection  and  the  details 
of  the  technic  for  intravenous  injection  carefully  observed.  Occasionally 
there  is  constitutional  reaction,  but  this  occurrence  is  unusual.  The  urine 
voided  at  ihe  cud  of  four  liours  and  at  hourly  intervals  thereafter  is  tested 
for  sugar  by  Nylander's  reagent.  ''See  page  302.  i  The  test  depends  upon 
the  time.     Over  six  hours  indicates  renal  insufficiency. 


636  MEDICAL  DIAGNOSIS. 

Elimination  of  Dyes  by  the  Kidneys. 

1.  Methylene  blue  and  indigo  carmine  have  been  extensively  employed 
as  tests  of  renal  permeability,  the  time  of  first  appearance,  that  of  maxi- 
mum intensity  and  that  of  total  excretion  were  noted  and  formed  the  basis 
of  deductions  concerning  the  function  of  the  kidneys.  Their  use  for  this 
purpose  has  been  almost  completely  superseded  by  the  phenolsulphonaph- 
thalein  test  of  Rowntree  and  Geraghty. 

2.  PhenolsulphonaphthaleinTest.1 — Twenty  minutes  to  half  an  hour 
before  giving  the  test  the  patient  is  given  200  to  400  c.c.  of  water  to  in- 
sure diuresis.  The  bladder  is  completely  emptied.  The  time  being  noted, 
1  c.c.  of  a  solution  of  the  drug  is  injected  into  the  lumbar  muscles.  The 
solution  is  prepared  as  follows :  .6  gm.  phenolsulphonaphthalein  and  .84  e.c. 
double  normal  XaOH  are  added  to  .75  per  cent.  NaCl  solution  up  to  100  c.c. 
Add  two  or  three  drops  of  double  normal  NaOH.  The  color  becomes  Bor- 
deaux red  and  the  solution  is  non-irritant. 

The  urine  is  passed  into  a  test  tube  containing  a  drop  of  25  per  cent. 
NaOH  and  the  time  of  appearance  of  the  first  pinkish  color  noted. 

If  there  is  no  urinary  obstruction  the  catheter  is  not  necessary  after 
the  appearance  of  the  color,  and  the  patient  may  then  retain  the  urine  and 
urinate  at  the  end  of  one  hour  in  one  receptacle  and  again  at  the  end  of 
the  second  hour  in  another. 

A  rough  estimate  of  the  time  of  the  appearance  of  the  drug  in  the 
urine  may  be  gained  by  having  the  patient  urinate  frequently  a  small 
amount  without  the  catheter.  In  prostate  cases  it  seems  better  to  keep  a 
catheter  in  situ.  If  this  is  done  the  catheter  may  be  corked  and  this  is 
removed  at  the  end  of  the  first  and  second  hours. 

Each  sample  of  urine  is  measured.  Twenty-five  per  cent,  solution 
NaOH  is  added  to  make  the  color  maximum.  The  urine  is  usually  yellow 
or  orange  and  becomes  deep  purple  on  addition  of  the  alkali.  The  solution 
is  put  in  a  liter  flask  and  diluted  with  distilled  water  to  make  a  quart. 
This  is  thoroughly  mixed  and  a  portion  is  filtered  and  compared  with  a 
standard  in  a  colorimeter.  The  standard  solution  consists  of  .003  gm. 
phenolsulphonaphthalein  (y2  c.c.  of  solution  used  for  injection)  diluted  to  1 
liter  and  made  alkaline  with  a  few  drops  of  25  per  cent.  NaOH.  The  test 
solution  retains  its  fine  purplish  color  for  a  Aveek  or  more. 

The  colorimeter  contains  a  wedge-shaped  cup  which  is  filled  with  the 
standard  solution.  The  rectangular  cup  is  filled  with  the  solution  to  be 
tested.  The  wedge-shaped  cup  is  manipulated  by  a  screw  until  the  color 
fields  are  identical.     The  percentage  is  read  off  on  the  indicator  scale. 

Technic  of  the  Phenolsulphonaphthalein  Test  as  Applied  to  Estima= 
tion  of  the  Function  of  the  Individual  Kidney. — Twenty  minutes  previ- 
ous to  the  application  of  the  test  the  patient  is  given  600  to  800  c.c.  of 
water  to  provide  a  free  flow  of  urine.  The  ureters  are  catheterized,  a 
special  catheter  being  recommended,  namely,  the  flute  end  catheter  of 
Albarran  No.  6  or  No.  7.  The  catheters  are  passed  four  inches  into  the 
ureters.  The  cystoscope  is  withdrawn,  leaving  the  catheters  in  situ.  A 
small  urethral  catheter  is  passed  into  the  bladder  to  empty  that  organ  and 

'Barton:  Manual  of  Vital  Function  Testing  Methods  and  Their  Interpretation.  2nd  edition.  Rowntree 
and  Geraghty:  Arch.  Int   Med..  1912.  ix,  284. 


FUNCTIONAL  TESTS.  637 

detect  later  leakage.     The  other  details  of  the  test  are  similar  to  those 
of  the  ordinary  technic  (q.  v.). 

"Where  only  one  test  can  be  employed  the  most  value  is  unquestion- 
ably to  be  obtained  from  the  use  of  phthalein ;  and  this  is  particularly  so 
from  the  standpoint  of  the  surgeons. ' '     Geraghty. 

TESTS  OF  PANCREATIC  FUNCTION. 

The  enormous  importance  of  the  pancreas  as  an  organ  of  digestion  and 
as  a  gland  of  internal  secretion  stands  in  strong  contrast  to  our  ability  to 
determine  its  functional  efficiency  in  either  of  these  respects  by  clinical 
or  laboratory  methods.  Except  in  the  case  of  gToss  changes  such  as  are 
associated  with  acute  pancreatitis,  certain  forms  of  pancreatic  diabetes 
and  manifest  lesions  as  tumor  or  cyst,  it  is  exceedingly  difficult  for  the 
clinician  to  recognize  the  presence  of  disease  of  this  organ  or  determine  the 
character  and  extent  of  the  pathological  process.  In  view  of  the  manifold 
and  complex  nature  of  its  physiological  functions  and  the  difficulties  which 
beset  their  experimental  study,  the  unsatisfactory  results  of  efficiency  tests 
are  not  surprising. 

Tests  of  Functio)ts  of  External  Secretion. — 1.  The  Examination  of 
the  Faeces.— The  stools  in  which  evidences  of  impairment  of  the  pancreatic- 
functions  of  digestion  are  present — as  an  excess  of  muscle  fibres,  undi- 
gested nuclei,  excess  of  fat  and  split  fats  and  an  excess  of  undigested 
starch  granules — are  usually  very  bulky.  If  formed  the  cylinders  are  of 
abnormal  diameter.  The  total  dried  faeces  may  weigh  150  grammes  instead 
of  the  normal  average  of  about  50  grammes. 

The  ordinary  methods  of  examination  should  be  preceded  for  three 
days  by  Schmidt's  diet,  which  contains  inconsiderable  amounts  of  all  three 
varieties  of  food  elements  and  is  therefore  well  suited  to  all  tests  which 
require  an  examination  of  the  faeces.    See  pages  226  to  232. 

2.  Test  for  Pancreatic  Ferments  in  the  Stools. — Methods  for  the 
qualitative  and  quantitative  estimation  of  trypsin,  diastase  and  the  liptolytie 
ferment  in  the  faeces  are  to  be  consulted  in  the  manuals  of  laboratory 
technic  but  they  are  of  little  practical  value  for  clinical  purposes. 

Tests  of  the  Function  of  Internal  Secretion  of  the  Pancreas. — These 
are  three : 

1.  The  Cammidge  Reaction.     (See  page  308.) 

2.  Spontaneous  and  Provocative  Alimentary  Glycosuria. — Glycosuria 
cannot  be  regarded  as  an  indication  of  disease  of  the  pancreas,  since  it 
may  have  its  origin  in  disease  of  any  of  the  so-called  diabetogenous  organs. 
This  yroup  includes  the  kidney,  the  liver,  the  thyroid,  the  chromaffin 
system,  the  hypophysis  and  the  central  nervous  system.  The  concurrence 
of  glycosuria  and  the  evidences  of  insufficiency  of  the  external  pancreatic 
secretion  warrants  the  hypothesis  that  the  diabetes  is  due  to  pancreatic 
disease.  That  such  is,  however,  the  case,  cannot  be  positively  affirmed  for 
the  reason  thai  cases  of  pancreatic  diabetes  may  occur  in  disorder  of  the 
internal  secretion  without  evidence  of  insufficiency  or  absence  of  the 
external  secretion. 

3.  The  Pupillary  Test  of  Pancreatic  Insufficiency. — Loewi  discovered 


638  MEDICAL  DIAGNOSIS. 

that  after  the  removal  of  the  pancreas  in  laboratory  animals  the  instillation 
of  adrenalin  causes  dilatation  of  the  pupil.  This  phenomenon  he  attributed 
to  an  increase  of  the  action  of  the  sympathetic  system  resulting  from 
the  absence  of  the  inhibitory  influence  of  the  internal  secretion.  Under 
normal  conditions  adrenalin  does  not  produce  mydriasis  when  injected  into 
the  conjunctival  sac,  although  it  does  so  when  injected  intravenously.  The 
est  is  made  by  the  instillation  of  3  or  4  drops  of  1 :1000  solution  of 
adrenalin  into  the  eye.  Mydriasis  comes  on  slowly,  reaching  its  maximum 
m  30  to  60  minutes. 

TESTS  OF  THE  FUNCTIONAL  CAPACITY  OF  THE  HEART. 

The  physiology  of  the  heart  is  extremely  complex.  Englemann  enumer- 
ated the  following  fundamental  attributes  of  the  cardiac  musculature: 
(1)  The  power  of  originating  contractile  impulses — the  dromotropic  func- 
tion; (2)  the  capacity  of  response  to  stimuli:  excitability — bathmotropic 
function;  (3)  the  faculty  of  conducting  impulses,  conductivity — the  dromo- 
tropic function;  (4)  the  property  of  contractility — the  inotropic  function; 
and  finally  (5)  the  vital  function  of  tonicity  in  consequence  of  which  the 
chambers  of  the  normal  heart  maintain  their  size  during  diastole. 

The  normal  interrelation  and  harmonious  exercise  of  these  functions 
result  in  the  maintenance  of  the  circulation  by  the  regular  alternation  of  the 
cardiac  systole  and  diastole  at  the  rate  in  healthy  adults  of  from  60  to  80 
revolutions  to  the  minute ;  in  infants  90  to  140 ;  in  the  aged  70  to  90. 
Extreme  variations  in  rate  and  power  occur  in  response  to  the  requirements 
of  the  individual  in  health  and  as  the  result  of  diseases.  Those  in  health 
are  as  a  rule  transient ;  while  the  departures  from  the  normal  rhythm  and 
force  which  result  from  disease  are  more  or  less  continuous,  and  those 
due  to  pathological  changes  in  the  heart  or  blood-vessels  are  usually  per- 
sistent. It  is  of  the  mechanism  of  the  heart  to  adjust  itself  within  wide 
limits  to  the  constantly  changing  needs  of  the  individual.  The  normal 
property  of  response  to  the  demand  for  more  power  has  been  spoken  of  as 
"the  reserve  power"  of  the  heart,  and  the  capacity  of  continuous  adjust- 
ment to  the  advancing  requirements  of  valvular'  lesions  which  constitutes 
compensation  is  attended  by  progressive  impairment  of  this  reserve.  The 
recognition  of  the  more  advanced  degrees  of  failure  of  compensation  is 
among  the  simplest  problems  of  clinical  medicine ;  there  are  no  tests  by 
which  the  beginnings  of  failure  may  be  determined.  The  recognition  of 
the  early  stages  of  functional  impairment  of  the  heart  constitutes  a  legiti- 
mate subject  of  laboratory  research,  but  the  results  both  as  regards  alike 
the  fundamental  functions  and  as  regards  the  absolute  power  of  the  heart 
are  thus  far  unsatisfactory  and  the  practitioner  must  content  himself  with 
the  older  clinical  methods  and  such  results  as  attend  the  present-day  use 
of  such  instruments  of  precision  as  the  polygraph,  sphygmodynamometer, 
electrocardiograph  and  the  rontgen-rays. 

There  are  four  general  groups  of  tests  of  cardiac  function : 

1.  Those  based  upon  the  reaction  to  active  or  passive  muscular 
movements. 

These  tests  depend  upon  the  influence  upon  cardiac  function,  as  mani- 


FUNCTIONAL  TESTS.  639 

fest  by  changes  in  the  pulse,  blood-pressure,  and  in  the  area  of  precordial 
dulness,  of  various  exercises,  changes  of  posture,  compression  of  peripheral 
arteries  by  the  use  of  a  tourniquet  or  bandage,  resisted  movements,  hold- 
ing the  breath,  elevation  of  the  arms,  and  so  forth. 

2.  Those  based  upon  cardiac  reflexes. 

This  group  includes  (a)  energetic  friction  over  the  heart.  If  the 
reflex  is  normal  the  area  of  cardiac  dulness  is  diminished. 

(b)  The  test  consists  in  making  a  series  of  strong  strokes  over  the 
median  line  of  the  abdomen.  A  positive  result  consists  in  an  increase  of 
cardiac  dulness  to  the  right. 

3.  Sodium  chloride  elimination  as  a  test  of  cardiac  function. 

A  constant  daily  quantity  of  sodium  chloride  is  given  for  some  days. 
An  equilibrium  being  determined,  the  daily  quantity  of  sodium  chloride  is 
doubled  and  a  quantitative  estimate  of  the  salt  in  the  urine  is  made.  In 
functional  cardiac  inadequacy,  even  though  latent,  the  salt  elimination  is 
defective  and  there  may  be  oedema.  The  permeability  of  the  kidneys  must 
be  determined  beforehand. 

4.  Instrumental  methods. 

(a)  The  sphygmomanometer  (see  page  124). 

(b)  Sphygmobolometry  and  sphygmobolography.1 

(c)  Energometry.2 

d     Electrocardiography  (see  page  112). 

In  conclusion,  the  following  quotation  from  Hirschfelder 3  is  preg- 
nant with  wisdom  for  the  practitioner : 

"It  must  be  admitted  that  in  order  to  be  decisive,  all  tests  have  to  be 
pushed  to  a  point  at  which  the  appearance,  sensation  and  signs  of  the 
patient  are  in  themselves  perfectly  characteristic  of  cardiac  insufficiency. 
and  at  which,  for  diagnostic  purposes,  a  little  common-sense  observatioE  is 
at  least  as  unambiguous  as  observation  with  elaborate  apparatus.  This 
does  not  mean  that  exercise  tests  are  unimportant,  On  the  contrary. 
they  are  of  the  greatest  value  and  no  change  in  the  patient's  mode  of 
living  during  convalescence  or  during  after-life  should  be  undertaken 
without  them. 

"But  their  importance  depends  more  upon  the  care  witli  which  the 
physician  watches  the  general  appearance  and  condition  of  the  patient,  the 
rapidity  with  which  he  recovers  from  the  exercise,  liis  general  condition  and 
whether  nervousness,  irritability,  cough  or  insomnia  have  set  in  during 
the  twenty-four  hours  following  it.  than  in  the  numerical  changes  which 
occur  at  the  moment  of  exercise.  The  symptoms  to  lie  Looked  for  as  evi- 
dence of  overwork  are  well  known.  These  are  subtler  manifestations  re- 
sulting from  smaller  changes  than  may  !"■  detected  by  even  the  most  refined 
observation  by  mechanical  methods  and  which  are  less  easily  masked  by 
ambiguil  ies. 

•'.Moreover,  it  must  he  realized  that  any  one  form  of  exercise  furnishes 
data  which  may  depend  ;is  much  upon  the  condition  of  the  skeletal  muscles 
as  upon  the  heart.    The  blacksmith  with  a  diseased  heart  may  he  able  to  do 


i  tmi  1.  <•.  p.  243  ■'  -"/  .  p.  251  • 
3i  i   Bai i"ii  1.  c,  p 
■  Diseases  "f  the  Heart  and  Aorta,  '-'<i  ed.,  J.  B. 


Lippincotl  Company,  Phila.,  1918,  p.  211,212. 


640  MEDICAL  DIAGNOSIS. 

more  work  than  the  bookkeeper  with  neurasthenia,  and  yet  under  the  con- 
ditions in  which  he  lives,  even  if  not  under  the  strength  test  arranged 
for  the  average  man,  the  blacksmith's  heart  may  be  failing.  The  important 
question  is  not  what  the  person  can  do  in  a  gymnasium,  but  what  he  can 
do  and  what  he  cannot  do  in  everyday  life.  Each  man  must  be  fit  for  his 
own  mode  of  life  or  must  be  made  to  change  it.  His  cardiac  power  must 
be  studied  with  reference  to  that  mode  of  life  rather  than  with  reference  to 
a  rigid  scheme." 

ENDOCRINE  GLANDS. 

The  opinion  prevalent  among  physiologists  until  recent  years  that  the 
chemical  processes  of  the  body  were  confined  to  the  building  up  and  break- 
ing down  of  various  tissues,  absorption,  combustion,  exertion  and  analogous 
processes  has  undergone  remarkable  changes.  It  is  now  recognized  that 
the  functions  of  the  body  are  regulated  not  only  by  nervous  influences  but 
also  by  chemical  substances  that  are  elaborated  by  certain  glandular  ex- 
cretions and  discharged  into  the  blood  stream.  These  substances  originate 
in  gland-like  organs  that  have  no  discharging  ducts,  as  the  thyroid,  the  para- 
thyroid, the  thymus,  the  adrenals,  the  hypophysis,  and  the  epiphysis— the 
glands  of  internal  secretion.  They  also  are  elaborated  by  certain  other 
glands,  which  possess  the  additional  function  of  secreting  a  fluid  which  is 
discharged  through  the  ducts — external  secretion.  The  glands  which  pos- 
sess this  double  function  include  among  others  the  liver,  the  pancreas,  the 
intestinal  mucosa,  and  sex  glands.  These  internal  secretions  exercise  a 
profound  influence  upon  the  growth,  development  and  metabolism  of  the 
body,  and  play  a  prominent  part  in  many  pathological  conditions  which 
arise  in  consequence  of  the  hyperfunction,  hypofunction,  or  dysfunction 
of  the  respective  glands,  derangements  of  their  reciprocal  relations  and 
aberrant  combinations,  such  as  arise  in  the  so-called  polyglandular  syn- 
dromes. (See  Diseases  of  the  Ductless  Glands,  Vol.  II.)  Practical  tests  of 
the  functions  of  these  most  important  organs  would  be  of  the  highest  value 
to  the  clinician,  but  despite  the  elaborate  investigations  thus  far  made,  are 
not  yet  available,  a  fact  due  partly  to  lack  of  exact  physiological  knowledge 
of  the  subject  and  partly  to  the  difficulties  which  attend  the  finer  research 
in  metabolism. 

Perhaps  the  sole  outcome  available  for  everyday  medicine  is  the  thera- 
peutic test  for  impaired  functional  efficiency  of  the  thyroid  gland.  If  in  a 
suspected  case,  thyroid  extract  be  administered  in  proper  doses,  the  prompt 
disappearance  of  the  symptoms  and  remarkable  improvement  in  the  general 
condition  of  the  patient  constitute  a  positive  reaction. 

Serology.1 

In  the  study  of  the  immune  reactions  of  the  blood-serum  and  the  ac- 
companying changes  found  in  the  cerebro-spinal  fluid,  we  have  a  series  of 
examinations  which  are  an  invaluable  aid  to  the  diagnosis  of  diseases  of  the 
central  nervous  system.  These  tests  provide  a  way  of  differentiating  between 
functional  and  organic  conditions  both  in  neurology  and  psychiatry,  and  in 


1  Contributed  by  Corson  White,  M.D.,  as  collaborator. 


SEROLOGY.  641 

syphilis  they  yield  not  only  a  means  of  early  diagnosis  but  act  as  a  guide  for 
treatment.  Experience  has  shown  that  a  diagnosis  should  in  no  case  be  de- 
cided upon  the  result  of  one  test,  but  all  examinations  of  proven  values 
should  be  investigated  and  the  correct  interpretation  be  made  upon  the  com- 
bined results  of  the  laboratory  findings  and  careful  clinical  studies. 

Many  important  facts  concerning  the  cerebro-spinal  fluid  were  demon- 
strated before  Quincke  (1891)  published  his  observations  on  the  technique 
and  value  of  lumbar  puncture.  Xo  decisive  studies  of  the  fluid  in  mental  or 
nervous  diseases  were  reported,  however,  until  1001,  when  the  investigations 
of  Ravaut  and  Sieard,  and  later,  Widal  appeared.  Since  then,  innumerable 
researches — bacteriological,  chemical,  serological  and  morphological — have 
been  published,  covering  syphilis  in  all  its  many  manifestations  and  all  types 
of  nervous  and  mental  diseases.  These  observations  have  placed  in  the  hands 
of  clinicians  a  mass  of  material,  most  of  which  is  of  immediate  value. 

The  removal  of  the  spinal  fluid  is  a  relatively  simple  procedure  and 
often  of  profound  significance  for  both  patient  and  physician.  Xo  elaborate 
preparation  is  necessary.  Two  (2)  glasses  of  water  given  just  before  the 
puncture  and  free  evacuation  of  the  bowels  will  usually  prevent  the  head- 
ache which  often  follows  the  withdrawal  of  the  fluid. 

The  patient  may  sit  on  a  stool  or  edge  of  bed  or  may  lie  on  the  left  side. 
If  the  recumbent  position  is  assumed  it  is  essential  that  the  patient  lie  on  a 
firm  surface,  so  that  the  midline  of  the  vertebral  column  and  head  is  straight. 
Many  failures,  so-called  dry  taps,  painful  punctures,  and  withdrawal 
of  bloody,  useless  fluids  are  undoubtedly  due  to  attempts  to  puncture  the  sub- 
arachnoid space  when  the  back  is  curved  by  reason  of  a  sagging  mattress.  In 
either  position  of  the  patient  the  back  must  be  arched  by  the  bending  forward 
of  neck,  head  and  shoulders,  and  the  drawing  up  of  the  knees  on  the  abdomen, 
the  ideal  position  being  that  one  which  gives  the  greatest  width  between  the 
spinous  processes  of  the  lumbar  vertebrae.  When  the  patient  is  in  position 
the  operator,  by  running  his  fingers  along  the  vertebral  spine,  selects  a  soft 
spot  between  the  third  and  fourth  or  fourth  and  fifth  lumbar  vertebra1.  The 
site  can  be  located  by  drawing  a  line  between  the  highest  part  of  the  iliac 
crests  across  the  spinal  column.  This  line  passes  through  the  interspace 
between  the  fourth  and  fifth  lumbar  vertebra',  which  is  the  point  of  election 
because  here  the  space  is  usually  the  widesl  and  there  is  less  danger  of 
injury  to  the  spinal  cord  or  sensory  nerve  roots. 

When  the  site  is  selected,  the  back  must  be  thoroughly  cleansed — abso- 
lute sterility  is  essential.  The  back  is  scrubbed  with  green  soap  and  hot 
water,  followed  by  hot.  water,  alcohol,  and  ether.  The  site  is  then  painted 
with  ten  per  cent.  (10$  )  iodine.  Many  operators  omit  the  preliminary 
cleansing  and  give,  instead,  three  coats  of  iodine. 

Before  the  actual  puncture  the  skin  may  be  rendered  less  son-dl  ive  by  in- 
jection of  cocaine,  eucaine  or  by  ethyl  chloride  spray.   In  some  cases,  notably 

paresis  and  tabes,  the  absence  of  all  pain  is  marked.  The  introduction  of  the 
needle  is  hardly  noticed  and  amesthesia  of  any  kind  is  not  essential.  General 
anaesthesia  is  rarely,  if  ever,  needed. 

The  needle  most  commonly  used  is  made  of  flexible  material,  preferably 

iridio-platinum,  1"  cm.  long  with  1  mm.  bore,  supplied  with  a  stylet  which  can 

be  locked  in  position  and  is  exactly  flush  with  the  sharp  but  short-pointed 

41 


642  MEDICAL  DIAGNOSIS. 

needle.  With  the  site  selected  and  cocainized,  the  needle  is  inserted  with  a 
sudden  thrust  directly  in  the  median  line  and  in  the  centre  of  the  interspace ; 
straight  forward  into  the  spinous  ligament,  then  more  slowly  into  the  canal. 
When  the  canal  is  reached,  which  is  evident  by  the  sudden  give  or  loss  of  re- 
sistance, the  stylet  is  removed.  Some  operators  prefer  the  insertion  of  the 
needle  (1  cm.)  to  side  of  spinal  column  in  the  interspace  between  fourth 
and  fifth  lumbar  vertebra?,  passing  the  needle  upward  and  inward  toward 
the  centre.  This  method  is  of  value  only  in  fat  subjects;  in  all  others 
the  central  position  is  much  easier  and  the  danger  of  touching  the  bone 
much  less. 

When  the  technique  has  been  properly  carried  out  the  fluid  should  be 
free  from  blood.  It  is  well,  however,  always  to  collect  the  spinal  fluid  in  two 
(2)  sterile  test  tubes,  in  case  the  first  be  contaminated  with  blood  or  tissue 
cells.  After  eight  (8)  or  ten  (10)  c.c.  have  been  collected  the  needle  should 
be  quickly  withdrawn  and  the  place  of  puncture  sealed  with  collodion. 

Ordinarily,  there  is  no  danger  in  lumbar  puncture  if  infection  be  care- 
fully excluded  and  the  fluid  is  slowly  withdrawn.  Occasionally,  the  needle 
may  touch  a  nerve  filament,  giving  rise  to  pain  in  the  distribution  of  that 
nerve,  or  the  operator  may  puncture  the  bone,  causing  a  dull  pain  which  may 
last  several  hours.  The  great  majority  of  patients,  especially  paretics  and 
tabetics,  are  little,  if  ever,  affected  by  the  removal  of  the  fluid.  There  is, 
however,  another  small  group  of  individuals,  representing  about  seven  to 
ten  per  cent,  of  those  punctured,  who  suffer  for  a  day  or  more  from  severe 
headache,  pain  in  the  back,  and  now  and  again  have  nausea,  vomiting,  and 
diarrhoea.  These  patients  are  usually  those  with  normal  fluid  findings. 
These  symptoms  are  not  serious  and  are,  easily  relieved  by  rest  in  bed  until 
no  return  of  the  headache  is  noticed  by  the  patient  when  sitting  up.  It  is 
well  to  have  all  patients  remain  in  bed  after  lumbar  puncture  for  at  least 
twenty-four  hours. 

In  no  sense  do  the  symptoms  recorded  above  constitute  a  contraindica- 
tion for  puncture.  There  exist,  however,  definite  contraindications.  Nonne, 
in  an  extremely  large  experience,  reported  four  fatal  results  immediately 
following  puncture — all  cases  of  brain  tumor.  Trocme  collected  thirty-five 
fatalities  from  the  literature,  one-half  of  which  occurred  in  cases  of  tumor 
of  the  posterior  fossa.  He  is  of  the  opinion  that  successful  puncture  could 
be  performed  in  these  cases  if  made  with  the  patient  in  the  recumbent  po- 
sition and  the  fluid  be  drawn  out  a  drop  at  a  time  and  limited  to  2  c.c. 
Kaplan  suggests  the  introduction  of  an  equal  amount  of  sterile  normal  salt 
solution  immediately  after  the  puncture  and  keeping  the  patient  in  bed  with 
the  foot  raised  about  twelve  inches. 

The  fluid  collected  from  the  spinal  puncture  should  be  fully  examined. 
Experience  has  taught  the  necessity  of  depending  in  no  case  upon  the  result 
of  one  examination.  Xo  parallelism  regularly  exists  between  any  abnormal 
finding  in  the  fluid  and  any  other.  One  cannot  say  that  because  one  test  is 
negative  another  will  be.  Conclusions  must,  therefore,  be  drawn  only  from  a 
careful  analysis  of  all  the  examinations  of  known  value  compared  with  the 
results  of  these  examinations  in  normal  fluid. 

Normal  cerebrospinal  fluid  is  a  transparent  water-clear  liquid  with 
a  sp.  gr.  of  1.002  and  1.007.    There  may  be  no  cells  found  in  the  examination, 


SEROLOGY.  643 

and  there  are  never  more  than  5  per  e.em.  Occasionally,  there  is  an  isolated 
endothelial  cell.  It  contains  a  faint  trace  of  protein,  the  major  part  of 
which  is  globulin.  It  is  always  sterile.  The  Wassermann  Reaction  and  other 
immune  reactions  are  absent.  The  value  of  other  immune  reactions  in  spinal 
fluid  is  not  established.  A  reducing  substance,  probably  a  sugar,  is  always 
present.  From  these  normal  findings  a  routine  examination  has  been 
developed  which  gives  most  decisive  information.  It  should  include  obser- 
vations on  pressure,  transparency  and  color — the  significance  of  which  is 
described  later ;  examination  for  increase  in  cells  and  for  increase  in  globulin 
content — tests  which  always  indicate  the  existence  of  organic  change  in  the 
brain  or  cord;  the  "Wassermann  Reaction — a  specific  test  for  the  detection 
of  syphilis;  and  the  colloidal  gold  reaction  which  differentiates  between 
paresis  and  other  types  of  syphilitic  disease.  The  technique  of  these  reac- 
tions can  be  found  in  any  work  on  laboratory  methods. 

Abnormal  Conditions. — The  great  majority  of  nervous  and  mental 
diseases  yield  a  fluid  of  normal  appearance.  Sometimes  on  withdrawal, 
especially  if  collection  of  the  fluid  is  made  entirely  into  one  tube,  there  may 
be  a  faint  cloudiness  due  to  blood-cells  washed  through  the  needle,  and 
recognized  only  when  they  have  been  deposited.  This  is  an  accident  of 
technique  and  can  be  avoided  by  collecting  in  two  tubes.  In  case  of 
hemorrhage  into  the  subarachnoid  space,  after  injury  to  the  skull  or  vertebral 
column  or  following  ventricular  hemorrhage,  a  definitely  bloody  fluid  may 
occur.  In  other  conditions,  as  meningitis  or  abscess,  cloudy  or  even  purulent 
fluids  may  be  found.  This  turbidity  is  due  to  immense  increase  in  cells  which 
separate  out  from  the  fluid  on  standing,  forming  a  definite  sediment.  This 
sedimentation  is  sometimes  found  in  fluids  which  on  first  sight  seemed  clear. 

Turbidity  occurs  most  frequently  in  bacterial  infections,  and  should 
always  call  for  a  bacteriological  examination.  A  more  important  discolora- 
tion is  xanthochromia.  This  fluid  has  a  lemon  yellow  color  about  the  shade 
of  pale  blood  serum.  It  shows  a  very  marked  increase  in  globulin:  very 
often  clots  spontaneously  and  contains  usually  only  a  normal  number  of 
cells  or  a  low  pathologic  count.  Nbnne  described  this  condition  as  a  spinal 
fluid  compression  syndrome.  All  the  cases  reported  occurred  in  paraplegias 
or  in  those  whose  symptoms  were  suggestive  of  cord  compression.  This  type 
of  fluid  has  been  observed  in  a  pachymeningitis  of  the  conns  terminalis  of 
syphilitic  origin,  in  tubercular-meningitis,  in  Pott's  disease,  Landry's 
paralysis,  pachymeningomyelitis,  spinal  cord  tumors,  extradural  and  intra- 
medullary, carcinomatous  metastases  of  the  vertebra.  The  marked  increase 
in  globulin  is  probably  due  to  stasis  distal  to  the  point  of  compression  and 
not  to  inflammation.  The  color  is  probably  due  to  a  mixture  of  blood — 
coloring  matter — from  an  old  hemorrhage  or  outwandered  red  cells.  The 
syndrome  does  qo1  differentiate  between  extradural  or  intramedullary 
growths,  nor  give  a  cause  for  the  compression.  It  is  simply  significant  of 
compression  of  the  spinal  cord. 

Pressure.  - — As  a  general  rule,  cerebrospinal  fluid  is  collected  with- 
out any  reference  to  the  pressure— other  than  noting  the  rate  of  flow  from 
the  eanula,  as  the  puncture  needle  reaches  the  dura!  sac 

It  is  frequently  advisable,  however,  to  know  exactly  the  height  of  this 
pressure.    One  may  resort  to  the  following  method  (Sahli)  which  is  a  modi- 


644 


MEDICAL  DIAGNOSIS. 


fication  of  the  method  originally  used  by  Quincke.  No  accurate  estimation 
is  possible  unless  the  patient  be  in  a  horizontal  position  with  the  median  line 
of  the  head  on  a  level  with  the  spinal  canal.  As  soon  as  the  needle  penetrates 
the  dura,  a  connection  is  made  with  a  mercury  manometer  by  means  of  a 
rubber  tube  filled  with  a  one  per  cent,  solution  of  carbolic  acid.  The  portion 
of  the  manometer  above  the  level  of  the  mercury,  forming  the  connection 
between  it  and  the  carbolic  acid  tube,  must  also  be  filled  with  the  fluid.  The 
manometer  is  filled  with  mercury  to  the  zero  point  and  held  in  such  a  manner 
that  this  point  is  on  a  level  with  the  point  of  the  aspirating  needle,  which 
is  possible  with  ordinary  manometers  only  when  the  connecting  tube  is  of 
considerable  length.  Under  normal  conditions  the  dural  pressure,  in  the 
horizontal  position,  ranges  between  5  and  7.5  mm.  of  mercury  or  60  to  100 

mm.  of  water  if  a  water  manometer  is  used. 

Under  normal  conditions  certain  oscillations 
of  pressure  occur.    In  respiration  there  is  a  move- 
ment of  about  20  mm.  depth — a  fall  with  inspira- 
tion and  a  rise  with  expiration.     There  is  also  a 
.slighter  variation  coincident  with  heart  pulsations. 
Great  increase  in  pressure  may  be  caused  by  cough- 
ing,   straining,    or    screaming.      A    still    greater 
increase  is  seen  during  muscular  resistance,  and 
this    probably    accounts    for    the    high 
pressure  observed  in  epileptics  during 
the  convulsions.     After  the  spasm,  the 
pressure  of  the  spinal  fluid  in  these  cases 
is  usually  normal. 

High  Pressure.— In  pathologic  con- 
ditions   the     pres- 


te^ 


Fig.205B. — Manometer  for  determinationofthepressure  ofthe  cerebro- 
spinal fluid.  Redrawn  after  Neisser.  The  scale  shows  the  absolute  value 
in  mm.;  the  pressure  measured  is  twice  the  reading.  Handb.  d.  Neurologie 
I,  p.  1180. 


sure  is  frequently 
high.  Generally, 
in  acute  disease  a 
moderate  degree  of 
pressure    increase, 

as  registered  on  the  manometer,  is  associated  with  severe  clinical  pressure 
symptoms,  while  in  chronic  conditions  the  registered  increase  may  be  much 
more  marked  with  symptoms  much  less  severe.  The  pressure  is  usually  high 
in  brain  tumor,  abscess,  and  inflammatory  conditions,  especially  those  with 
much  exudate. 

In  hydrocephalus  the  pressure  is  usually  high  and  the  fluid  is  easily 
evacuated  by  lumbar  puncture.  Certain  cases,  however,  those  due  to  some 
obstruction  to  the  normal  outlets  from  the  ventricles,  may  show  only  a  low 
or  normal  pressure.  The  greatest  help  of  a  diagnostic  nature  is  found  in  the 
study  of  pressure  in  cases  of  intracranial  hemorrhage  either  from  trauma  or 
apoplexy.  A  bloody  spinal  fluid  of  high  pressure  is  associated  with  concus- 
sion, fracture  of  the  skull  or  other  trauma,  or  with  ventricular  hemorrhage. 
This  last  may  yield,  however,  a  perfectly  clear  fluid.  Capsular  hemorrhage, 
on  the  other  hand,  exhibits,  as  a  rule,  a  fluid  water  clear  and  of  low  or 
normal  pressure. 


SEROLOGY.  645 

Low  Pressure. — Low  spinal  fluid  pressure  readings  are  quite  fre- 
quent in  cases  with  low  blood-pressure,  in  collapse,  and  chronic  debility.  A 
low  spinal  fluid  pressure,  in  cases  exhibiting  signs  of  intracranial  pressure, 
denotes  some  obliteration  of  the  upper  part  of  the  cerebro-spinal  canal,  as  by 
exudate,  impermeability  of  foramen  of  Magendie,  or  occlusion  of  foramen 
magnum  by  the  brain  itself.  This  situation  is  that  which  occurs  in  cases  of 
hydrocephalus  showing  low  pressure.  It  may  also  happen  in  acute  serous 
effusions,  oedema  of  the  brain,  as  well  as  in  the  more  chronic  conditions,  such 
as  tumors  of  cerebellum  or  tumor  of  the  posterior  fossa.  Often  in  these 
cases  the  first  reading  is  high,  but  after  the  removal  of  one  or  more  cubic 
centimetres,  it  falls  very  rapidly  to  below  normal — showing  no  tendency  to 
rise  again.  This  is  due  to  the  entire  blocking  of  the  foramen  magnum, 
which  before  was  only  slightly  permeable.  It  is  always  serious,  ending 
frequently  with  fatal  result. 

Serology  has  been  developed  primarily  in  the  study  of  syphilis,  and, 
therefore,  in  attempting  to  review  the  results  in  nervous  and  mental  diseases 
it  is  well  to  divide  the  entire  field  into : 

(1)  Those  conditions  which  are  manifestations  of  syphilis. 

(2)  Those  symptom-complexes  which  may  or  may  not  be  an  expression 
of  syphilitic  disease. 

(3)  The  serological  findings  in  those  lesions  due  to  organisms  other 
than  spirochaeta  pallida. 

(4)  Those  conditions  of  unknown  origin  but  which  are  never  due  to  or 
associated  with  syphilis. 

The  first  group  includes  all  the  clinical  complexes  which  are  directly 
traceable  to  luetic  infection:  syphilis,  skin,  visceral,  nervous,  tabes,  and 
general  paralysis.  In  infections  an  early  recognition  offers  the  best  and 
often  the  only  chance  of  successful  therapy.  The  value  of  serology  lies  in 
the  fact  that,  by  means  of  such  examinations  the  disease  may  be  detected  in 
its  incipience  before  any  permanent  tissue  change  has  occurred. 

At  the  time  of  infection,  the  period  of  the  chancre,  the  only  decisive 
diagnostic  factor  is  the  presence  of  the  spirochete  in  the  sore.  This  is 
easily  demonstrated  in  smears.  The  Wassermann  Reaction  of  the  blood  re- 
mains negative,  as  a  rule,  until  about  the  fourteenth  day,  when  it  becomes 
positive,  increasing  in  intensity  from  then  on  until  in  the  secondary  stage  it 
is  strongly  positive. 

The  spinal  fluid  has  not  been  extensively  studied  during  this  period  of 
the  disease.  The  German  literature  has  some  records  of  spinal  fluid 
examinations,  but  all  with  negative  results.  It  is  very  probable  that  the 
invasion  of  the  cerebro-spinal  axis  does  occur  very  early  in  the  disease  in 
some  individuals.  Plant  reports  a  syphilitic  cerebral  meningitis  in  a  patient 
whose  initial  sore  had  not  healed;  a  spinal  fluid  Wassermann  was  not  made 
in  this  case. 

In  the  secondary  static  the  staye  of  generalized  infection,  the  serological 
findings  are  most  decisive.  Practically  100  per  cent,  of  the  cases  give  a 
strong  positive  Wassermann  Reaction  with  the  blood.  The  number  of  spinal 
fluid  examinations  made  is  still  small,  but  of  sufficient  magnitude  to  prove 
without  doubt  that  a  small  percentage  show  definite  involvement  of  the 
nervous  system.    Ten  per  cent,  of  the  ca.ses  studied  show  pleocytosis — that  is, 


646  MEDICAL  DIAGNOSIS. 

more  than  ten  cells  per  c.em.  Nonne  in  his  studies  thought  that  a  moderate 
cell  increase  was  probably  present  in  40  per  cent,  of  all  cases  of  infection, 
without  denoting  any  involvement  of  the  central  nervous  system.  The 
globulin  is  increased,  however,  in  about  13.3  per  cent,  of  cases  examined,  and 
this  always  indicates  the  existence  of  organic  changes  in  the  brain  or  cord. 
The  pressure  is  normal,  as  a  rule,  but  may  be  increased ;  Wassermann  Re- 
action of  the  spinal  fluid  is  positive  in  between  10  and  15  per  cent,  of  the 
cases.  A  number  of  definite  cases  of  cerebro-spinal  syphilis  have  been 
reported  in  men  still  presenting  an  eruption. 

The  majority  of  secondary  cases  examined  in  full  give  positive  blood 
Wassermann ;  negative  spinal  fluid  Wassermann ;  negative  globulin  test ;  posi- 
tive Fehling's  test;  cells  one  to  five  per  c.cm. ;  colloidal  gold  test  is  absolutely 
negative  or  inconstant.  The  significance  of  this  gold  reaction  when  present 
in  the  fluid  is  not  known.  Approximately  35  per  cent,  of  the  secondary 
cases  examined  showed  some  changes  in  the  spinal  fluid ;  about  10  per  cent, 
have  all  the  spinal  fluid  tests  positive,  the  more  usual  combination  of  these 
latter  cases  being  positive  blood  Wassermann ;  negative  spinal  fluid  Wasser- 
mann ;  slight  increase  of  globulin;  negative  colloidal  gold;  cells  three  to  35. 

It  is  very  important  to  note  that  in  these  cases  showing  definite  abnor- 
malities in  the  spinal  fluid,  practically  none  showed  symptoms  suggestive  of 
involvement  of  the  central  nervous  system.  On  the  basis  of  the  reported 
cases  less  than  one  per  cent,  of  the  patients  with  secondary  syphilis  show 
coincident  cerebro-spinal  symptoms,  yet  more  than  35  per  cent,  show  spinal 
fluid  changes. 

In  tertiary  syphilis  the  serology  will  vary  definitely  with  the  localization 
of  the  infections.  Cases  exhibiting  skin  or  visceral  lesions,  as  a  rule,  show 
normal  spinal  fluids — i.  e.,  with  negative  Wassermann  Reactions ;  negative 
globulin ;  negative  colloidal  gold ;  positive  Fehling's  test ;  and  cells  one  to  five 
per  cm.  As  soon,  however,  as  the  nervous  system  is  involved,  and  usually 
long  before  there  is  any  clinical  manifestation  of  the  involvement,  the  spinal 
fluid  will  become  definitely  pathologic,  and  the  pathology  of  the  fluid  will 
vary -with  the  anatomic  localization  of  the  luetic  focus  in  the  nervous  system. 
Many  serologists — Nonne,  Dreyfus,  Plaut,  etc. — have  attempted  the  establish- 
ment of  formulas  for  spinal  fluid  findings  in  nervous  syphilis,  fitted  to  these 
anatomic  localizations.  Syphilis  may  be  predominatingly  cerebral  or  spinal, 
or  a  combination  of  both.  It  may  be  acute  or  chronic.  It  may  involve 
primarily  and  almost  exclusively  the  meninges,  inner  walls  of  the  arteries, 
or  the  brain  and  cord  tissue  itself.  The  serological  findings  in  these  different 
types  of  syphilitic  lesions  are  more  or  less  distinct,  and  while  no  hard  and 
fast  lines  can  be  drawn  as  to  the  type  of  findings,  the  formulas  occur  with 
sufficient  frequency  to  be  of  considerable  diagnostic  value.  In  acute  syph- 
ilitic meningitis  a  turbid  fluid  may  occur ;  more  often  it  is  clear.  The  pres- 
sure is  almost  invariably  high.  The  cell  count,  made  up  for  the  most  part 
of  small  mononuclear  cells,  is  high,  averaging  between  150  and  3,000.  The 
more  acute  the  case  the  higher  the  number  of  polymorphonuclear  cells  found, 
and  with  the  increase  in  polymorphonuclear  cells  comes  the  diminution  in 
the  strength  of  the  Fehling's  reduction  test,  which  in  some  cases  may  be 
entirely  negative.  The  Fehling's  test  is  usually  present,  but  where  absent 
or  diminished  it  always  is  indicative  of  a  very  active  process.     Globulin  is 


SEROLOGY.  647 

excessive  and  the  spinal  fluid  YTassermann  positive.  The  blood  is  also 
positive  in  about  90  per  cent,  of  these  cases.  In  the  more  chronic  types  of 
syphilitic  meningitis  the  blood  AYassermann  is  positive  in  about  90  per 
cent,  of  the  cases ;  spinal  fluid  YVassermann  is  60  per  cent.,  using  a  routine 
of  0.2  e.c  of  fluid  for  the  test.  With  larger  doses  of  spinal  fluid  100  per 
cent,  are  found  to  be  positive ;  the  globulin  test  is  positive  aud  the  number 
of  cells  varies  from  about  150  to  1,800.  Fehling"s  solution  is  promptly 
reduced. 

When  the  syphilitic  virus  attacks  primarily  the  inner  lining  of  the 
blood-vessels — the  endarteric  type — the  blood  serum  almost  always  gives  a 
positive  Wassermami  Reaction.  The  spinal  fluid  gives  a  positive  reaction  in 
only  about  60  per  cent.  Globulin  increase  is  absent  or  slight ;  cells  are  nor- 
mal border  line  or  low  pathologic  count,  3-20.  Fehling's  reduction  is  always 
prompt. 

In  the  gummatous  form  involving  brain  or  cord  tissue,  the  serology  will 
vary  according  as  there  is  more  or  less  coincident  meningitis.  The  average 
serology  is  positive  YVassermann  Reaction  in  blood  and  spinal  fluids ;  cells 
varying  from  ten  to  one  hundred ;  a  positive  globulin  increase,  that  as  a  rule  is 
not  excessive  :  colloidal  gold  reaction  showing  the  greatest  precipitation  of  the 
gold  in  the  dilutions  one  to  eighty  and  one  to  one  hundred  sixty,  and  in 
these  tubes  it  is  very  seldom  complete.  Fehling's  reduction  is  prompt.  The 
value  of  the  colloidal  gold  test  is  in  these  cases  considerable.  It  is  frequently 
essential  to  differentiate  between  cerebral  syphilis  and  paresis.  In  syphilis 
the  spinal  fluid  Wassermann  is  much  weaker,  often  not  demonstrable  with 
the  smaller  amounts  of  fluid.  The  paretic  spinal  fluid  Wassermami  is 
usually  very  strongly  positive  with  0.2  c.c.  of  fluid.  The  cerebral  syphilis 
gold  curve  is,  as  a  rule,  0.013,310,000,  while  the  paretic  curve  is  almost  in- 
variably 5555543.100.  There  occur  cases,  clinically  identical  with  paresis,  in 
which  all  the  serological  examinations  are  those  of  cerebral  syphilis,  and 
;iLi;iin  eases  which  clinically  would  be  classed  as  cerebro-spinal  syphilis  whose 
blood  and  spinal  fluid  are  of  paretic  type.  There  are  not  sufficient  autopsy 
records  to  decide  decisively  on  the  relative  merits  of  these  reactions  in 
eases  of  this  kind. 

1.  In  tabes  dorsalis  the  blood  and  spinal  fluid  examinations  are  of  great 
importance,  especially  in  the  pre-tabetic  stage — i.e.,  when  the  patient  has  not 
well-defined  neurological  symptoms,  but  complains  of  vague  pains — 
rheumatism,  stomach  and  intestinal  troubles,  etc.  These  symptoms  should 
always  call  for  serological  examination,  especially  if  in  the  background  is  a 
syphilitic  history.  The  serological  findings  in  these  cases  are  of  more 
diagnostic  importance  than  the  Argyll-Robertson  pupils  and  absent  knee 
jerks,  because  they  are  demonstrable  sooner.  In  a  clear-cut,  full-fledged 
case  the  laboratory  is  not  nearly  so  valuable.  The  more  common  findings  in 
tabes  dorsalis  is  Wassermann  positive  in  blood-,  negative  in  spinal  fluid,  ex- 
cept where  large  doses  of  spinal  fluid,  <>.•">  to  1  cc.  are  tested.  The  globulin 
reaction  is  negative  or  only  weakly  positive;  cells  varying  from  2.1  to  1<»i>; 

Fehling's  reduction  is  prompt;  colloidal  gold  ^i\iie_r  inconstanl  results,  en- 
tirely negative  or  the  luetic  type  of  curve.  Many  cast's,  however,  may  have 
negative   blood;    positive   spinal    fluid:   while   still   others   may    have   all 


648  MEDICAL  DIAGNOSIS. 

reactions  and  tests  positive ;  the  cells — 50  to  80  per  c.cm.,  and  a  colloidal  gold 
curve  which  may  be  leutic  in  type  or  show  a  distinctly  paretic  curve. 
Whether  this  last  should  really  be  classed  as  tabo-paresis  cannot  be  cleared 
without  further  autopsy  studies;  certainly  many  cases  with  this  form  of 
serology  show  no  symptoms  whatever  of  paresis. 

In  paresis,  again,  the  period  of  extreme  importance  for  serological  ex- 
aminations is  long  before  the  symptoms  of  paresis  are  established.  All  care- 
ful serologists  and  clinicians  to-day  are  convinced  that  little  is  gained  in 
the  treatment  of  fully  developed  paresis,  either  clinically  or  serologically. 

All  vague  symptoms  occurring  in  an  individual  known  to  have  had  a 
luetic  infection  should  excite  suspicion  and  call  for  full  serological  examina- 
tion. In  the  longer  or  shorter  pre-paretic  stage  much  could  be  done  if  the 
conditions  were  discovered.  The  incipient  stage  of  paresis  has  no  fixed 
formula.  No  one  grouping  of  blood  and  spinal  fluid  findings  means  abso- 
lutely beginning  paresis.  The  more  usual  result  of  these  examinations  based 
on  a  large  series  of  cases  that  have  ended  as  typical  cases  of  general  paralysis, 
was  a  strongly  positive  Wassermann  Reaction  of  the  blood,  that  was  influ- 
enced very  little,  if  at  all,  by  intensive  treatment — i.e.,  a  persistent  strongly 
positive  reaction  in  blood ;  a  negative  reaction  in  the  spinal  fluid,  associated 
with  moderate  increase  in  the  globulin  content ;  a  cell  increase,  as  a  rule,  of 
more  than  60  cells ;  a  colloidal  gold  test  showing  complete  percipitation  of 
the  gold  in  the  dilution  1  to  10,  1  to  20,  1  to  40,  1  to  80,  and  1  to  160. 

In  a  full-fledged  typical  case  of  general  paralysis  every  reaction  is  posi- 
tive. The  Wassermann  Reaction  in  both  blood  and  spinal  fluid  is  very  strongly 
positive,  comparable  in  intensity  only  with  the  reaction  as  it  is  found  in 
secondary  syphilis  at  the  height.  The  lesions  here  are  parenchymal.  The 
spirochetes  are  placed  deeply  in  the  brain  substance.  The  meningeal  irri- 
tation is  slight  and  the  globulin  increase  and  cell  count  (17  to  50)  moderate. 
Fehling's  solution  is  promptly  reduced;  the  cells  found  in  the  fluid  are 
practically  100  per  cent,  lymphocytes.  The  colloidal  gold  test  is  very 
decisive ;  the  average  being  complete  precipitation  charted  ■  empirically 
as  5,  in  the  dilution  1  to  10,  1  to  20,  1  to  40,  1  to  80,  1  to  160,  and  1  to  320 ; 
moderate  precipitation  1  to  640 ;  less  in  1  to  1,280.    None  in  other  tubes. 

In  the  late  stages  of  paresis,  the  stage  of  complete  dementia  and  general 
decline,  the  reactions  may  all  continue  positive  or  they  may  all  become  neg- 
ative. They  may  become  entirely  negative  with  treatment — slight> 
moderate  or  intensive — or  with  no  treatment  whatever. 

Mitchell,  Newcomb  and  Darling  reported  a  series  of  spinal  fluid,  cell 
counts,  etc.,  made  in  untreated  paretics.  The  fluid  was  taken  every  two 
weeks  for  a  period  of  some  twenty  weeks.  The  highest  counts  occurred  in 
full-fledged  cases,  especially  those  showing  excitement  and  grandiose  ten- 
dencies ;  but  they  also  occurred  in  some  patients  with  marked  dementia  and 
in  some  with  comparative  remissions.  In  some  of  their  individual  cases 
very  great  variations  in  the  counts  occurred  from  week  to  week,  as  30  to  150 ; 
2  to  15;  0  to  30;  0  to  60 — with  apparenty  no  change  in  the  patient's  con- 
dition. It  is  evident  from  their  reports  that  a  reduction  to  a  normal  count 
may  occur  in  this  disease  without  any  treatment,  other  than  the  drainage. 

Many  reports  of  cure  in  paresis  have  appeared  in  the  literature  based 


SEROLOGY.  649 

on  the  absence  of  the  ordinary  reactions,  the  dementia  being  explained  as 
the  result  of  the  previous  disease.  In  judging-  the  result  of  any  treatment  it 
is  essential  to  remember  the  tendency  to  remission  in  this  disease  with  and 
without  improvement  in  the  serology,  and  to  variations  in  the.  serological 
findings  with  and  without  any  clinical  improvement. 

A  low  count  may  arise  and  continue  for  months.  The  globulin  excess 
also  may  vary.  The  most  common  serological  combination,  however,  in  the 
late  stages  of  paresis  is  negative  blood  Wassermann  Reaction;  positive 
spinal  fluid  Wassermann;  negative  globulin  excess  (or,  if  present,  a  weak 
reaction)  ;  cells,  35  or  less — often  none;  a  prompt  reduction  of  Fehling's 
solution,  and  a  colloidal  gold  reaction  which  retains  its  typical  paretic  type. 

Definite  conclusion  concerning  treatment  should,  therefore,  not  be  based 
on  fall  in  cell  count,  globulin  or  even  Wassermann  reactions,  unless  there 
is  a  coincident  and  permanent  clinical  improvement,  especially  when  it 
is  realized  that  falling  counts  and  loss  of  other  reactions  are  not  un- 
common before  death  in  paresis  and  occur  very  frequently  in  rapidly 
progressive  ca.ses. 

About  3  per  cent,  of  the  patients  examined  may  be  entirely  negative  in 
both  blood  and  spinal  fluid  before  death  and  show  spirochete  in  the  brain 
tissue  at  autopsy. 

In  congenital  syphilis  the  serology  is  the  same  as  in  the  adult  type. 
1  nder  treatment  the  tests  of  blood  and  spinal  fluid  tend  to  become  normal. 
The  closer  the  treatment  to  the  initial  infection  the  more  prompt  and  per- 
manent is  the  result.  With  the  intravenous  injection  of  Salvarsan,  the 
blood  Wassermann  generally  disappears  first.  With  the  Swift-Ellis  intra- 
spinal treatment  the  cell  count  is  first  influenced,  probably  as  much  by  the 
removal  of.  the  fluid  as  by  the  administration  of  the  serum.  The  result  of 
the  treatment,  as  evidenced  by  the  return  of  blood  and  spinal  fluid  to  nor- 
ma] findings,  is  least  encouraging  in  tabes  and  general  paralysis.  All  ex- 
udative conditions  are,  as  a  rule,  promptly  influenced  by  therapy — both 
serologically  and  clinically,  although  there  is  no  hard  and  fast  rule  as  to 
which  finding  will  disappear  first. 

2.  The  next  great  value  of  serological  examination  lies  in  those  condi- 
tions which  may  or  may  not  be  caused  by  syphilis.  When  syphilis  is  the 
etiological  factor  the  examinations  will  give  the  ordinary  leutic  results. 
previously  described.  In  a  few  conditions,  other  tests  have  been  devised 
which  add  some  decisiveness  to  the  results,  but  as  a  rule  the  only  role  of 
serology  is  to  eliminate  syphilis  as  a  cause. 

An  endarteric  syphilis  may  give  rise  to  hemiplegia — embolism,  throm- 
bosis, cerebral  softening,  or  to  the  cerebral  palsies  of  children  with  tin-  typical 
serology  of  spinal  syphilis.  When  due  to  any  other  cause  the  results  of  the 
blood  and  fluid  examinations  in  all  these  lesions  are  uniformly  negative. 

Hydrocephalus  usually  is  entirely  negative.  In  acute  eases  there  may 
be  a  marked  cell  increase  and  the  globulin  may  be  excessive.  Pressure  is  al- 
ways high.    In  post-traumatic  hydrocephalus  there  is  an  increased  pressure 

and  increased  amount  of  fluid,  but  cells  and  globulin  are  generally  normal. 
In  concussion  with  fracture,  however,  there  may  be  a  clear  or  bloody  fluid, 
increased  pressure,  and  cells  that  may  or  may  not  he  increased;  globulin  is 


650  MEDICAL  DIAGNOSIS. 

usually  normal,  but  may  also  be  increased.  It  will  always  be  excessive  in 
bloody  fluids. 

In  fracture  with  infection  the  fluid  becomes  turbid:  pressure  very 
high ;  globulin  markedly  increased ;  bacteriological  examination  shows  the 
infecting  organism. 

A  gumma  or  tuberculoma  may  give  rise  to  the  clinical  picture  of  brain 
tumor,  and  the  gumma  gives  the  ordinary  leutic  serology.  A  true  brain 
tumor  is  usually  associated  with  a  normal  blood  and  spinal  fluid — the  latter 
under  increased  pressure.  Rarely  there  may  be  a  slight  increase  in  cells, 
seldom  above  the  border  line  counts.  A  globulin  increase  may  be  present  or 
absent,  dependent  upon  the  position  of  the  tumor  and  the  presence  or  absence 
of  meningeal  irritation. 

The  diseases  of  the  spinal  cord — excluding  cerebro-spinal  syphilis, 
tabes  dorsalis  and  inflammations — are  practically  all  entirely  negative 
serologically. 

Combined  sclerosis  gives  entirely  normal  results  with  the  routine 
serological  examination,  but  is  usually  associated  with  more  or  less  severe 
blood  changes.  A  few  cases  show  an  increase  in  the  globulin  content  of  the 
spinal  fluid  unassociated  with  a  cell  increase.  This  type  of  spinal  fluid  may 
be  found  also  in  syringomyelia,  hematomyelia,  disease  of  the  cauda?quina, 
tumor,  Pott's  disease,  and  a  few  other  conditions. 

The  serology  of  spinal  cord  tumors  will  depend  on  the  nature  of  the 
tumor,  a  gumma  giving  the  ordinary  luetic  reactions.  The  compression 
syndrome  of  Xonne  is  a  not  uncommon  finding — that  is,  the  lemon  yellow 
color  xanthochroma,  enormously  increased  globulin  reaction  with  little  or  no 
increase  in  cells.  Most  of  these  fluids  coagulate  spontaneously.  Fehling's 
reagent  is  at  times  not  reduced. 

Involvements  of  the  nerves  are  almost  invariably  negative  to  luetic 
tests.  Spinal  fluid  findings  are  entirely  negative,  herpes  zoster  alone  at  times 
showing  a  moderate  cell  increase — 3  to  20  cells. 

Functional  neurosis  and  insanities  may  occur  in  syphilitic  persons,  but 
in  those  not  leutic  the  serology  is  uniformly  negative.  This  is  true  also  of 
epilepsy,  tetany,  chorea,  paralysis  agitans.  Graves's  disease,  myxoedema, 
acromegaly,  myasthenia  gravis,  etc. 

Aside  from  those  conditions,  which  now  and  again  are  caused  by  or 
associated  with  syphilis,  there  is  a  large  group  due  entirely  to  infections 
which  have  a  serology  of  their  own. 

3.  In  the  infections  of  the  meninges  the  "Wassermann  Reaction  is  in 
all  save  syphilitic  meningitis  negative  in  both  blood  and  cerebro-spinal  fluid. 
The  globulin  is  always  increased,  and  increased  as  a  rule  to  a  greater  extent 
than  is  found  in  any  case  of  syphilis.  The  cell  count  ranges  from  100  to 
30,000,  often  too  many  for  accurate  count  without  dilution.  The  highest 
cell  counts  observed  occur  in  infections  due  to  the  streptococcus.  The  cells, 
except  in  tubercular  meningitis  are  predominantly  polynuclear;  Fehling's 
solution  is  usually  not  reduced;  colloidal  gold  tests  are  very  irregular  and 
of  little  value.  Most  meningitic  spinal  fluids  precipitate  the  gold  in  the 
tubes  of  higher  dilution,  as  1  to  320  and  1  to  640. 

In  these  cases  the  most  important  part  of  the  examination  is  the  study 


SEROLOGY.  651 

of  the  cytology  and  bacteriology.  In  the  majority  of  cases  the  bacteria,  can 
be  demonstrated  in  smear  preparations,  and  yet  in  all  cases  cultures  should 
be  made.  In  tubercular  meningitis  the  fluid  may  be  clear  or  faintly  opal- 
escent :  globulin  is  increased  and  the  increase  can  be  demonstrated  even  after 
diluting  the  fluid  five  times.  The  cells  are  small  mononuclear  lymphocytes 
and  may  vary  from  60  to  30,000,  usually  between  200  and  300.  Organisms 
may  be  found  in  smears;  more  often  none  are  found  or  found  with  great 
difficulty,  and  animal  inoculations  will  be  necessary.  In  meningococcus  in- 
fection— epidemic  cerebro-spinal  meningitis — the  cells  for  the  most  part 
'  polynuclear)  rise  to  several  thousand  per  c.cm.,  often  too  abundant  to  ac- 
curately count.  The  globulin  is  greatly  in  excess.  Other  proteins  are  also 
increased  to  demonstrable  amounts.  Fehling's  reduction  is  absent.  Smears 
made  from  the  sediment  show  numerous  gramme  negative  intracellular  dip- 
lococci.  These  grow  on  Lofner's  blood  serum  or  ascitic  broth  containing  1  per 
cent,  dextrose.  Blood  serum  of  infected  cases  contains  specific  agglutinins 
for  meningococcus.  With  pneumococcus  infection,  a  full-fleclsred  menin- 
gitis is  common  with  typical  meningeal  fluid  reactions  and  yielding  pneu- 
mococcus on  culture.  It  is  possible  to  have  during  a  general  infection  a 
spinal  fluid  from  which  pneumococcus  can  be  cultured,  but  without  any 
clinical  signs  of  meningitis.  The  spinal  fluid  may  or  may  not  have  a  cell 
increase  or  globulin  increase.  It  may  be  turbid  or  clear.  The  great  majority 
of  cases  of  pneumonia,  however,  have  sterile  spinal  fluid. 

Besides  the  meningitis  due  to  meningococcus,  pneumococcus  and  tubercle 
bacilli,  exactly  similar  conditions  with  the  same  kind  of  spinal  fluid  findings 
occur  with  infection  by  bacillus  of  influenza,  diphtheria,  typhoid,  paraty- 
phoid, staphylococcus,  streptococcus,  and  more  rarely  B.  eoli,  B.  pyocyaneus, 
B.  mallei,  B.  anthracis,  saccharomyces,  actinomyces.  The  globulin  and  cell 
content  are  uniformly  increased,  the  degree  of  excess  varying  with  the  viru- 
lence of  the  invading  organism.  Meningitis  has  also  been  caused  by  trichina 
spiralis. 

This  type  of  spinal  fluid  also  occurs  to  a  lesser  degree  in  cerebral  ab- 
scess. If  the  abscess  is  well  encapsulated  the  fluid  may  be  entirely  negative. 
The  degree  of  spinal  fluid  changes,  as  a  rule,  is  dependent  on  the  amount 
of  meningitic  reaction.  A  negative  result  can  also  occur  when  communi- 
cation with  subarachnoid  space  is  shut  off.  Cell  count  may  then  be  border 
line  and  globulin  excess  very  mild.  Fehling's  reduction  test  is  positive,  ex- 
cept in  fluids  which  become  filled  with  pus  cells. 

Encephalitis  and  cerebritis  have  followed  mumps,  erysipelas,  typhus, 
malaria,  influenza,  and  pneumonia.  It  is  not  uncommon  after  infected  head 
wounds.  Symptoms  arc  those  of  meningitis.  There  is  an  increase  in  cerebro- 
spinal fluid;  an  increased  spinal  pressure;  the  cell  counl  of  the  spinal  fluid 
is  never  very  high;  globulin  increased  bu1  never  excessive ;  cultures  of  blood 
and  cerebro-spinal  fluid  may  be,  and  generally  are,  sterile. 

In  myelitis  sterile  fluids  are  more  often  found  than  those  yielding 
organisms  on  culture.  <  lells  may  be  normal  or  very  slightly  raised  ;  globulin 
is  generally  very  little  increased  ;  the  blood  cells  usually  show  changes;  blood 
cultures  are  usually  negative ;  Fehling's  reduction  tesl  is  weak,  or  absent. 

In  anterior  poliomyelitis  cultures  on  ordinary  media  are  negative.    The 


652  MEDICAL  DIAGNOSIS. 

fluid  is  infective  because  of  a  filterable  virus  which  it  contains.  Wassermann 
Reaction  in  blood  and  spinal  fluid  is  always  negative.  At  an  early  stage  of 
the  disease,  especially  before  the  onset  of  the  paralysis,  the  spinal  fluid  shows 
a  moderately  increased  cell  count  with  a  low  or  normal  globulin  content. 
Polynuclear  cells  may  represent  at  this  time  at  least  90  per  cent,  of  the 
total,  but  usually  the  cells  are  almost  entirely  made  up  of  lymphocytes  and 
large  mononuclear  cells.  After  the  first  two  weeks  the  cell  count  drops  to 
normal  or  nearly  normal  and  there  is  frequently  an  increase  in  the  globulin 
which  persists  for  seven  weeks  or  longer.  All  fluids  reduce  Fehling's 
solution. 

There  exists  one  other  group  of  meningeal  conditions  where  the  serology 
is  more  or  less  distinctive.  These  are  hypertrophic  spinal  meningitis  and 
pachymeningitis  hemorrhagica.  The  Wassermann  Reaction  in  the  blood  and 
spinal  fluid  is  always  negative.  There  are  no  cells,  but  a  marked  excess  of 
protein,  albumen  and  globulin,  which  coagulates  on  heating.  In  pachymen- 
ingitis hemorrhagica  the  fluid  may  have  a  distinct  pink  color,  due  to  blood 
coloring  matter. 

4.  In  all  the  other  neurological  or  psychiatric  conditions  serology  offers 
little  of  moment.  Many  studies,  as  H-ion  content,  urea,  uric  acid,  cholesterin 
content,  etc.,  have  added  to  our  sum  total  of  knowledge  but  yielded  nothing 
of  clinical  help.  From  these  clinical  studies  a  few  facts  have  been  col- 
lected. In  uraemia  there  may  be  an  increase  in  chlorides  in  the  cerebro- 
spinal fluid  without  a  corresponding  increase  in  urea,  while  in  other  cases 
there  may  be  an  increase  in  urea.  In  diabetes  the  glucose  is  often  markedly 
increased.  Acetone  is  frequently  present  and  diacetic  acid  has  been  found, 
but  only  in  very  profound  intoxications.  Acetone  has  also  been  found  in 
cases  of  Addison's  disease. 

Resume. — Serology  which  includes  examination  of  blood  and  spinal 
fluid  establishes : 

1.  By  means  of  the  "Wassermann  Reaction : 

(a)  A  method  of  diagnosing  syphilis; 

(b)  Of  eliminating  syphilis  as  a  causative  agent; 

(c)  Of  detecting  syphilis  as  a  complicating  factor. 

2.  By  means  of  the  colloidal  gold  reaction : 

(a)   Method  of  differentiating  paresis  from  less  malignant  forms  of 
syphilis. 

3.  By  means  of  the  globulin  test  and  cell  count : 

fa)   A  method  of  differentiating  organic  from  functional  diseases. 

4.  By  means  of  bacteriological  examination : 

(a)   Determining  the  causative  agents  in  cases  of  infections. 

Allergy:  Anaphylaxis:  Serum  Sickness. 

These  terms  are  used  in  a  general  way  to  designate  the  train  of  symp- 
toms caused  by  protein  poisoning. 

Foreign  proteins,  though  constantly  introduced  into  the  alimentary 
canal,  do  not  under  normal  conditions  gain  access  to  the  fluids  and  tissues  of 
the  body.  To  do  this  they  must  first  be  acted  upon  by  the  proteolytic  fer- 
ments of  the  digestive  fluids  and  split  up  into  less  complex  bodies  as  peptons 


ALLERGY:  ANAPHYLAXIS:  SERUM  SICKNESS.  653 

and  amido  acids,  in  which  form  they  pass  through  the  mucosa  of  the  digestive 
tract  to  gain  access  to  the  interior  of  the  organism. 

Under  certain  circumstances,  however,  foreign  proteins  reach  the  fluids 
and  tissues  of  the  body  without  having  undergone  changes  in  their  con- 
stituent form.  This,  as  Vaughan  has  pointed  out,  occurs  in  three  different 
ways : 

First,  As  the  result  of  abnormal  permeability  of  the  intestinal  mucosa 
in  certain  individuals  for  particular  proteins.  Under  this  heading  are  to  be 
grouped  the  various  food  idiosyncrasies  described  further  on.  The  striking 
peculiarities  of  this  form  of  protein  poisoning  are  the  rapidity  with  which 
the  symptoms  develop  after  the  ingestion  of  the  offending  article  of  food, 
the  minuteness  of  the  quantity  capable  of  giving  rise  to  intense  symptoms, 
and  the  specific  nature  of  the  poisoning  as  manifest  in  the  prominence  of 
cutaneous  and  respiratory  manifestations. 

Second,  Parenterally,  that  is  to  say,  not  by  way  of  the  mucosa  of  the 
digestive  tract,  but  directly  into  the  fluids  and  tissues  by  experimental  injec- 
tion or  the  use  of  therapeutic  sera. 

If  a  normal  guinea-pig  receives  a  small  amount  of  normal  horse  serum 
by  injection  subcutaneously.  intravenously  or  into  the  peritoneum  no 
apparent  change  takes  place.  Nevertheless  remarkable  effects  have  been 
produced  in  the  fluids  and  tissues  which  do  not  manifest  themselves  until 
a  later  period  and  under  definite  specific  conditions.  If,  after  several 
weeks,  the  animal  thus  treated  is  again  injected  with  the  'same  dose  of 
normal  horse  serum,  urgent  symptoms  immediately  occur  and  death  may 
follow.  The  horse  serum,  which  upon  the  first  injection  had  no  manifest 
effect,  has  become  on  the  second  injection  an  intense  poison.  A  proper  inter- 
val of  time  must  elapse  between  the  two  injections  for  the  manifestation  of 
these  changes.  If  the  re-injection  is  performed  in  the  course  of  a  few  days 
no  toxic  phenomena  result.  This  "  condition  of  unusual  or  exaggerated  sus- 
ceptibility of  the  organism  to  foreign  proteins  "  (Rosenau)  has  been  desig- 
nated anaphylaxis. 

Third,  Foreign  protein  may  enter  the  body  as  the  result,  of  bacterial  in- 
fection. Under  these  circumstances  the  cellular  elements  which  constitute  the 
proteins  have  the  capacity  of  growth  and  multiplication  after  their  introduc- 
tion into  the  body.  During  this  process  certain  body-cells  are  stimulated  to 
the  production  of  an  enzyme  capable  of  destroying  the  pathogenic  organism. 
"As  the  bacterial  cell  is  broken  up  under  the  influence  of  the  special  enzyme, 
poisonous  products  are  liberated  which  exert  their  harmful  action  and  give 
rise  to  the  symptoms  of  illness.  This  special  ferment,  once  formed,  remains 
in  the  body  after  recovery  from  the  disease,  and  is  stored  up  in  certain  cells 
as  a  zymogen  for  future  use.  When  subsequently  a  bacterial  cell  of  the  same 
species  again  enters  the  body,  its  presence  at  once  reactivates  the  zymogen 
already  formed,  and  consequently  the  invading  organism  is  destroyed  before 
it  has  had  opportunity  to  grow  and  multiply  to  any  extent.  As  ;i  result  of 
this  fact  the  individual  once  affected  has  acquired  an  active  immunity  to 
subsequent  attacks  of  the  same  disease."1 

Allergy. —  Von  Rirquet,  basing  his  conclusions  <m  a  series  of  clinical 
observations.  BUggested  this  term,  which  literally  means  altered   reaction,  to 

designate  the  phenomena  under  consideration  without  indicating  any  theo- 

1  VniKhan,  V.  C,  Jr.  Int.rri.it.  Clinir-s,  vol.  IV,  2 1st  Series,  p.   142,  J.  B.  Lippinoott  Co.,  1911. 


654  MEDICAL  DIAGNOSIS. 

retieal  explanation  for  them.  In  view  of  the  complexity  of  the  subject,  the 
enormous  amount  of  research  carried  out,  and  the  abundance  of  new  facts 
collected,  without  the  attainment  up  to  the  present  time  of  any  satisfactory 
conclusive  generalizations,  it  would  have  been  better  to  have  retained  the 
word  ' '  allergy  ' '  in  preference  to  anaphylaxis.  Allergy  has  been  employed 
in  a  different  sense  to  indicate  the  effort  of  the  body  to  localize  the  activity 
of  the  spirochete,  which  tends  to  be  generally  distributed  in  syphilis,  after 
prolonged  infection ;  an  effort  sometimes  seen  in  the  early  secondary  period, 
but  more  usual  in  the  tertiary  stage,  when  the  lesions  are  not  infrequently 
limited  to  one  or  two  areas. 

Anaphylaxis. — This  term,  meaning  "  without  protection,"  was  intro- 
duced by  Richet,  and  has  come  into  general  use,  though  at  the  present  time 
its  appropriateness  may  well  be  questioned,  since  the  actual  condition  is 
regarded  as  in  many  cases  favorable  to  the  development  of  immunity.  It 
is  differently  employed  by  writers  upon  the  subject.  Some  use  it  to  designate 
the  anatomical  and  functional  changes  which  occur  when  an  animal  receives 
under  the  required  conditions  a  second  injection  with  the  same  protein  solu- 
tion. Others  employ  it  to  describe  the  sensitized  state  produced  by  the  first 
injection  of  some  foreign  soluble  protein,  while  others  again  apply  it  to  the 
sensitization  produced  by  the  first  injection  and  the  intoxication  caused  by 
the  second  injection  of  the  same  protein. 

The  term  is  not  applicable  to  the  toxic  reactions  which  occur  when 
any  one  of  a  large  number  of  very  different  substances  are  injected:  nor 
should  it  be  used  to  designate  the  condition  when  the  injection  is  repeated 
in  three  or  four  days — that  is,  before  the  expiration  of  the  definite  period — ■ 
and  the  animal  remains  perfectly  normal.  It  is  the  development  of  charac- 
teristic toxic  phenomena  upon  the  second  injection  of  the  same  soluble 
protein  after  the  expiration  of  the  appropriate  interval  that  constitutes 
anaphylaxis. 

This  being  the  case,  anaphylaxis  may  be  considered  in  three  dif- 
ferent phases :     (a)  sensitization;  (b)  incubation;  and  (c)  intoxication. 

(a)  Sensitization  may  be  caused  by  any  soluble  foreign  protein,  either 
animal  or  vegetable,  introduced  in  an  unaltered  state  into  the  circulatory 
fluids  of  an  animal.  The  list  is  a  very  large  one  and  comprises:  1,  animal 
proteins  in  solution;  2,  cellular  animal  proteins,;  3,  vegetable  proteins 
in  solution ;  4,  cellular  vegetable  proteins.  The  sensitizing  dose  varies 
in  different  animals.  The  most  susceptible  animal  is  the  guinea-pig,  but 
it  is  probable  that  every  species  of  animal  may  be  sensitized.  Other  ordi- 
nary laboratory  animals,  as  the  rabbit,  are  less  susceptible.  In  the  case 
of  the  guinea-pig  the  dose  of  horse  serum  or  crystallized  egg  albumen  is 
practically  infinitesimal.  The  most  certain  method  of  inducing  laboratory 
sensitization  is  the  injection  of  the  selected  protein  subcutaneously,  intra- 
venously or  into  the  peritoneal  sac.  Other  methods  consist  in  feeding  the 
proteid  substances  to  animals,  their  inunction  into  the  scarified  skin,  and 
their  repeated  introduction,  particularly  that  of  horse  serum,  into  the 
nares  or  into  the  vagina  or  rectum  of  guinea-pigs.  It  has  also  been  estab- 
lished that  sensitization  in  the  case  of  guinea-pigs  may  be  transmitted  from 
the  mother  to  her  offspring.  These  experimental  proofs  that  sensitization 
may  be  inherited  or  acquired  by  the  contact  of  proteins  with  the  uninjured 


ALLERGY:  ANAPHYLAXIS:  SERUM  SICKNESS.  655 

mucous  membranes  or  integuments  may  be  invoked  to  explain  the  more  or 
less  violent  anaphylactic  reaction  which  sometimes  occurs  in  human  beings 
upon  the  first  injection  of  an  antitoxin  for  therapeutic  or  immunizing- 
purposes  and  certain  idiosyncrasies. 

That  sensitization  is  specific  is  fully  established  by  the  fact  that  a 
reaction  can  only  be  obtained  by  the  reinjection  of  the  same  protein  used 
in  the  first  injection  or  a  protein  derived  from  an  animal  or  vegetable  of  a 
closely  related  group. 

(&)  The  incubation  is  the  interval  required  by  the  body  fluids  and 
tissues  to  undergo  these  changes  which  endow  the  soluble  foreign  protein, 
practically  harmless  upon  the  first  injection,  with  the  properties  of  a  viru- 
lent poison.  Sensitization  develops  gradually  and  reaches  its  maximum 
at  varying  periods  in  different  animals.  In  the  guinea-pig  the  incubation 
is  complete  in  about  ten  days ;  in  the  rabbit,  eight  to  fifteen  days  after  the 
last  of  several  injections  (Arthus  phenomenon)  ;  in  man,  seven  to  twelve 
days.  The  duration  also  varies  with  different  animals.  In  man  typical 
reactions  have  occurred  upon  reinjection  after  five  years. 

(c)  Intoxication.  It  is  in  this  phase  that  anaphylaxis  declares  itself. 
The  period  of  incubation  may  be  completed,  and  sensitization  gradually 
and  fully  established,  to  gradually  subside  after  a  shorter  or  longer  interval ; 
but  the  animal  remains  practically  normal  unless  it  is  injected  with  the 
same  protein.  AVhen  this  happens  acute  or  subacute  symptoms  of  intoxi- 
cation promptly  supervene  and  the  requirements  of  the  concept  designated 
anaphylaxis  are  fulfilled.  These  symptoms  vary  in  different  animals,  but 
are  practically  constant  in  the  same  species,  whatever  the  protein  may  be 
that  causes  them.  In  man  cutaneous  lesions  are  common  and  usually  accom- 
panied by  respiratory  and  circulatory  derangements. 

In  the  laboratory  intoxication  is  brought  about  by  the  same  methods 
by  which  sensitization  is  caused:  in  man  by  the  inhalation  or  ingestion  of 
the  .sensitizing-  protein  or  by  the  use  of  immunizing  sera.  In  general  terms. 
the  quantity  of  foreign  protein  required  to  cause  intoxication  is  much 
greater  than  the  quantity  which  sensitizes. 

It  has  been  generally  accepted  that  the  protein  molecule  acts  both  as 
the  sensitizing  and  the  intoxicating  substance.  Vaughan  has  shown  that 
proteins  are  split  into  a  toxic  and  nontoxic  fraction  by  prolonged  exposure 
to  a  high  temperature  in  a  2  per  cent,  solution  of  sodium  hydrate  in  abso- 
lute alcohol.  The  toxic  fraction  causes  fatal  anaphylactic  phenomena  in 
guinea-pigs  but  does  not  sensitize  them.  The  non-toxic  fraction  causes 
sensitization  which  reacts  to  the  entire  protein  molecule  but  fails  to  react 
to  the  non-toxic  fraction.  This  experimental  work  forms  the  basis  of  the 
parenteral  digestion  theory  of  anaphylaxis  formulated  by  Vaughan  and 
is  regarded  as  the  most  acceptable  explanation  of  the  subject  presented  up 
to  the  present  time.  Its  main  points  have  been  set  forth  in  foregoing 
paragraphs. 

Anti-aiiapliylaxis  according  to  this  view  constitutes  a  condition  in 
which  there  Is  a  disproportion  between  the  amount  of  the  specific  fermenl 
and  the  foreign  protein,  .since  the  anaphylactic  reaction  calls  for  much  of 
the  ferment,  and  the  remainder  is  incapable  of  releasing  a  sufficient  quan- 
tity of  the  poison  to  cause  reaction.     Passive  anaphylaxis  is  the  condition 


656  MEDICAL  DIAGNOSIS. 

caused  by  the  transference  of  the  specific  proteolytic  zymogen  from  a  sensi- 
tized animal  to  a  normal  one. 

The  intoxication  symptoms  in  the  human  being  comprise  cutaneous 
eruptions,  severe  arthalgias,  swelling  of  the  lymph-nodes,  fever  of  remit- 
tent type,  oedema,  albuminuria  and  leukopenia. 

Serum  Sickness. — This  term  was  applied  by  von  Pirquet  and  Schick 
to  the  well-defined  symptom-complex  of  anaphylactic  reactions  which 
sometimes  occur  in  man  after  the  injection  of  therapeutic  sera,  most  of 
which  are  obtained  from  the  horse. 

These  symptoms  occasionally  occur  not  only  after  injections  of  anti- 
diphtheritic,  antistreptococcic  and  other  sera,  but  they  may  also  follow 
the  injection  of  normal  horse  serum.  They  are  therefore  not  due  to  the 
antibodies  present  in  the  serum  but  to  the  serum  itself.  It  has  also  been 
established  that  these  reactions  are  more  common  in  cases  treated  with  large 
amounts  of  serum  than  with  small  amounts  of  serum  containing  the  same 
number  of  antitoxin  units.  It  has  further  been  shown  that  serum  derived 
from  certain  horses  is  more  frequently  followed  by  anaphylactic  reactions 
than  of  other  horses  injected  in  similar  amounts. 

In  a  majority  of  the  cases  the  typical  intoxication  reaction  does  not 
occur  until  the  end  of  an  incubation  period  of  about  eight  to  twelve  days. 
Among  the  earlier  symptoms  are  fever,  which  may  last  from  a  few  days 
to  a  week  or  two  j  enlargement  and  tenderness  of  the  lymph-nodes  in  the 
area  of  the  injection ;  and  eruptions  at  first  urticarious,  subsequently  of 
the  most  polymorphous,  description  and  symmetrically  distributed.  During 
the  incubation  period  there  is  a  moderate  leucocytosis,  which  gives  place  to 
a  marked  but  transient  leucopo?nia.  Joint  affections  are  less  common  and 
involve  usually  the  metacarpophalangeal  articulations,  the  wrists  and  the 
knees.  They  are  painful,  but  tend  to  recovery  without  disability  or  de- 
formity. The  cedema  appears  first  in  the  face ;  later  in  the  dependent  parts 
of  the  body.  There  is  also  a  slight  albuminuria.  The  subsidence  of  the 
glandular  swelling  and  disappearance  of  the  oedema  are  of  favorable  prog- 
nostic significance,  since  they  are  shortly  followed  by  recovery. 

In  an  individual  who  has  had  previous  injections  of  horse  serum  this 
typical  reaction  is  modified  in  respect  of  the  time  of  its  occurrence.  There 
are  two  types  of  modification :  First,  an  immediate  reaction,  which  occurs 
within  twenty-four  hours,  and  second,  an  accelerated  reaction,  which 
occurs  about  the  fifth  or  seventh  day.  When  the  injection  is  made  in  from 
ten  days  to  six  months  following  the  primary  injection  the  immediate  reac- 
tion commonly  appears;  after  six  months  the  accelerated  reaction.  In 
other  respects  the  reactions  are  similar  to  those  of  a  primary  injection,  but 
run  a  shorter  course. 

As  a  rule  the  serum  sickness  in  man,  as  characterized  by  the  foregoing 
symptoms  and  manifesting  the  immediate  and  accelerated  reactions,  runs 
a  favorable  course  and  terminates  in  recovery.  It  has  occasionally  occurred, 
however,  that  a  violent  or  fatal  anaphylactic  shock  has  promptly  followed 
the  first  injection  of  horse  serum,  even  in  small  amounts.  These  accidents 
are  fortunately  of  infrequent  occurrence.  The  symptoms  resemble  those 
of  anaphylactic  shock  in  laboratory  animals,  and  it  may  be  assumed  that 
they  are  due  to  similar  causes.     The  larger  proportion  of  the  cases  have 


ALLERGY:  ANAPHYLAXIS:  SERUM  SICKNESS.  657 

suffered  from  intense  dyspnoea  and  convulsions,  while  the  pulse  continued 
for  a  time  full  and  regular.  At  autopsy  in  some  instances  the  lungs  were 
found  overdistended.  These  manifestations  closely  resemble  the  fatal 
anaphylactic  shock  of  the  guinea-pig.  A  history  of  asthma  or  other  respira- 
tory affections  usually  has  been  obtained.  A  careful  anamnesis  bearing 
upon  these  conditions,  and  especially  upon  the  occurrence  of  asthmatic 
symptoms  following  exposure  to  the  effluvia  from  horses,  should  be  made 
in  cases  in  which  injections  of  sera  are  indicated.  In  a  more  limited  group 
of  cases  the  first  injection  of  horse  serum  has  caused  anxiety,  profound 
depression,  cyanosis  and  great  feebleness  of  the  action  of  the  heart-collapse 
symptoms  such  as  occur  in  the  anaphylactic  shock  of  the  rabbit  and  dog. 
Many  of  these  patients  have  never  received  a  previous  injection  of  horse 
serum.  The  intense  symptoms  and  acute  death  cannot  be  attributed  to 
an  essential  toxicity  of  the  serum,  for  first  injections  of  horse  serum  not 
only  as  a  general  rule  do  not  cause  anaphylactic  phenomena,  but  they  usually 
do  not  produce  immediate  symptoms  of  any  kind.  The  reactions  are  dis- 
tinctly those  of  an  anaphylactic  intoxication  of  the  most  violent  character 
and  develop  with  characteristic  promptness.  It  must  be  assumed  that  they 
are  due  to  a  sensitized  condition  of  the  subject,  the  result  of  the  parenteral 
digestion  of  unchanged  horse  protein  absorbed  by  the  intestinal  tract  or 
in  one  of  the  other  ways  by  which  laboratory  animals  undergo  experimental 
sensitization. 

The  recurrence  of  hay  fever,  hay  asthma,  horse  asthma  and  the  various 
food  idiosyncrasies  are  instances  of  anaphylaxis  of  the  milder  type.  There 
is  reason  to  suspect  that  all  cases  of  asthma  are  manifestations  of  protein 
sensitization,  and  that  the  common  occurrence  of  asthmatic  seizures  in 
persons  suffering  from  chronic  affections  of  the  respiratory  tract  results 
from  an  anaphylactic  reaction  to  the  proteins  of  the  infecting  organisms 
by  which  such  affections  are  caused. 

Idiosyncrasy. — This  term  has  long  been  used  to  describe  the  condition 
in  whi<*h  the  inhalation  of  the  effluvium  of  animals,  especially  the  horse, 
rabbit  or  guinea-pig,  or  of  the  pollen  of  a  great  variety  of  different  plants, 
or  the  ingestion  of  certain  articles  of  food,  among  which  may  be  particu- 
larly named  eggs,  cheese,  pork,  shell-fish,  buckwheat,  and  strawberries,  is 
directly  followed  by  urgent  and  distressing  symptoms.  Asthma  and  urti- 
carial rashes  are  almost  constant,  but  abdominal  distress  and  pain,  vomiting, 
diarrhoea  and  prostration  are  common  and  sometimes  severe.  This  con- 
dition of  hypersensitiveness  is  anaphylactic  in  character  and  specific, 
antibodies  for  the  particular  protein  being  present  in  the  cells  and  fluids 
of  the  affected  individual,  it  is  also  extreme,  as  the  most  intense  symptoms 
often  follow  the  inhalation  of  exceedingly  minute  amounts  of  protein  in 
horse-asthma,  while  the  instillation  of  a  few  drops  of  a  1  per  cent,  physiologic 
salt  solution  of  pollen  into  the  lachrymal  sac  n\'  a  susceptible  individual  is 
sufficient  to  cause  an  attack  of  hay-fever.  This  form  of  anaphylaxis  is 
common  and  often  hereditary.  The  circumstances  under  which  sensitiza- 
tion has  taken  place  are  mostly  unknown.  The  sufferer  is  usually  aware  of 
the  particular  animal,  pollen  or  article  of  food  which  causes  his  attacks  and 
is  on  the  wateh  to  avoid  it. 

Some   persons  are  sensitized  to  particular  drugs,   among  which   are 

42 


658  MEDICAL  DIAGNOSIS. 

atropine,  strychnine,  morphine,  iodoform,  ipecac  and  certain  preparations 
of  iron,  and  suffer  severely  after  exceedingly  small  doses.  If  under  these 
circumstances  the  drug  in  question  does  not  contain  a  protein  substance  it 
is  necessary  to  assume  that  it  may  act  upon  a  body  protein  and  convert  it 
into  a  foreign  protein,  capable  of  sensitizing  other  cells  of  the  body. 

The  diagnosis  of  idiosyncrasy  rests  upon  the  fact  that  the  patient 
almost  invariably  upon  exposure  to  the  emanations  from  particular 
animals,  the  inhalation  of  certain  pollens  or  the  ingestion  of  definite  articles 
of  food  or  drugs  suffers  at  once  from  the  characteristic  train  of  symptoms. 

Cutaneous  and  intracutaneous  tests  are  successfully  employed  in  the 
case  of  food  idiosyncrasy.  The  technic  of  the  cutaneous  tests  consists  in 
cleansing  the  skin  of  the  arm  with  alcohol,  abrading  a  small  area  by  a 
needle  or  other  suitable  instrument  and  rubbing  into  the  abraded  surface 
a  minute  portion  of  the  suspected  article,  as  a  drop  of  egg  albumen  or  a 
drop  of  a  5  per  cent,  watery  solution  of  the  food.  A  positive  reaction 
appears  in  ten  minutes  or  less  in  the  form  of  an  urticarial  wheel  sur- 
rounded by  an  erythematous  areola,  and  lasts  from  twenty  to  forty-five 
minutes.  A  control  must  be  made  with  water  or  salt  solution,  since  the 
trauma  itself  may  be  followed  by  some  oedema  and  redness  in  persons  with 
an  irritable  skin. 

The  intracutaneous  test  consists  in  the  injection  into  the  skin  of  a 
minute  amount  of  a  sterile  solution  of  the  protein  of  the  suspected  food— 
0.1  c.c.  of  0.1  per  cent,  solution  is  usually  sufficient.  A  positive  reaction 
is  seen  in  a  tender  papule,  with  oedema  and  an  erythematous  areola.  This 
test  is  very  delicate  but  somewhat  painful.  Confusing  non-specific  reactions 
are  common,  but  subside  in  a  short  time.  For  this  reason  the  readings 
should  not  be  taken  until  after  forty-eight  hours.  Soluble  proteins  of 
foods  are  prepared  for  these  tests  in  the  biological  laboratories  and  sold 
in  the  shops.  The  offending  food  may  not  always  be  found  at  once  and  a 
series  of  tests  may  then  become  necessary. 

The  prognosis  may  be  favorable  if  the  offending  protein  is  found  and 
desensitization  undertaken  by  the  systematic  feeding  of  the  offending  food 
in  minute  and  non-toxic  doses  with  each  meal  until  the  skin  reaction  becomes 
negative ;  the  same  result'  may  be  attained  by  the  subcutaneous  injections 
of  sterile  solutions  of  the  offending  protein,  beginning  with  minimal  doses 
and  increasing  by  degrees. 


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